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Music therapy

David Aldridge Collected Papers


ALDRIDGE

The Music of the Body:


Music Therapy in Medical Settings
David Aldridge What strikes me is the fact that in our society,
art has become something which is related only
to objects and not to individuals, or to life. That
art is something which is specialized or done by
If w e consider our human biology experts who are artists. But couldn't everyone's
in terms of musical form rather than life become a work of art? Why should the lamp
mechanical construction and our or the house be an art object, but not our life?
response to biological challenges I
-Michael Foucault (in Rabinow 1986)
I
as a repertoire of improvisations,
w e may find that disease restricts The use of music as a healing agent appears
our ability t o improvise new to be common to many cultures. Since David
first played to soothe King Saul, there has
solutions to challenges-in musical been the recognition that music can bring
terms, restricts our ability to play relief to the afflicted. That the affliction in
improvised music. Saul's case is usually presented as depression,
though it might well have been an acute ep-
isode of asthma, only serves to emphasize
both the difficulty of historical interpretation
and the generalness of reports about music as
therapy. An earlier article in Advances, Robert
Omstein and David Sobel's "Coming to Our
Senses" (19891, reminds the reader of the
necessity of enjoying the senses for the pro-
motion of health. This paper goes one step
further and presents the use of music as ther-
apy, as it appears in the medical literature
during the last decade. (References to psy-
chiatric settings have been excluded.)

T h e medical and nursing press contains


a series of overviews about music therapy,
ranging from letters to full-scale articles. The
principle emphasis in this material is on the
soothing ability of music and on the value
of music as an antidote to an overly techno-
logical medical approach (Bailey 1985; Brody
David Aldridge, Ph.D., is associate professor of 1988; Carlisle 1990; Fischer 1990; Harcourt
clinical research in the Faculty of Medicine at 1988; Harvey & Rapp 1988; Kartman 1984;
the University of Witten Herdecke in Germany, McDermit 1984; Morris 1985; Olivier 1986;
and the European editor for the journal The Arts Ornstein & Sobel 1989; Paren t-Bender 1986;
in Psychotherapy. He is the coeditor (with Pouget 1986; Rowden 1984; Stem 1989; Thom-
George Lewith) of a handbook of clinical research as 1986; Wein 1987; Ziporyn 1984). Most of
methods for complementary medicine (Hodder these articles are concerned with what is
and Stoughton 1992). called passive music therapy-the playing of

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Music therapy has been studied as Readers may be surprised to learn that
music therapy has been studied as an aid
an aid in treating specific medical in treating a variety of medical problems,
problems, including coronary including coronary care, cancer pain manage-
care, cancer pain management, ment, and neurological disorders. In this
and neurological disorders. article, we shall move from general consider-
ations to specific observations. We begin with
the general use of music in hospital settings,
and then turn to detailing the use of music
usually prerecorded music to patients-and therapy to treat particular problems.
they emphasize the necessity of healthy
pleasures like music, fragrance, and beau-
tiful sights in reducing stress and enhancing Music Therapy
well-being. in General Medicine
Music therapy is actually more varied
and more complex. In some methods the pa- For a while after World War I1 music therapy
tient is indeed a "passive" listener, and live, was intensively used in American hospitals
or recorded music, is played at the discretion in the rehabilitation of the wounded, with the
of the therapist. But even in this situation, aim of raising their morale and as a relief
some therapists challenge the term "passive," from the tedium of hospital life (Schullian &
insisting that listening is an active process. Schoen 1948).Psychiatrists were quick to see
This is supported, for example, by an ap- the benefits of music for enhancing mood and
proach that uses imagery stimulated by se- promoting relaxation in their patients. Since
lected musical passages (Bonny 1978; Bonny then some hospitals, in mainland Europe
1975; Ornstein & Sobel1989). Other methods particularly, have incorporated music therapy
of music therapy consist of or include active within their practice (Aldridge & Verney
playing of musical instruments and singing, 1988; Goloff 1981; Jedlicka & Kocourek 1986;
individually or in groups. Some of these McCluskey 19831, carrying on a tradition of
approaches incorporate musical improvisa- European hospital-based research into the use
tion as the key component of the therapeutic of music as therapy (Leonidas 1981).
activity. The postwar European initiatives were
concerned with rehabilitation and psychiatry.
There is growing evidence to support However, with the development of the per-
the claims of music therapists that music can spectives of psychosomatics, and with a
contribute to healing, although the research growing tolerance of alternative and comple-
methodologies used to substantiate such mentary medical initiatives, music therapy in
claims often lack scientific rigor or are uncon- Europe has been applied to a wide range of
ventional in their approach. It is important to medical problems, including cancer care, the
emphasize that some music therapists reject treatment of patients with severely compro-
quantitative research outright. They believe mised immune systems, the management of
that such methods discount the important pain, and the relief of anxiety.
individual and qualitative aspects of their The nursing profession in particular
work as artists working in medical settings, has promoted the general value of music
and seek to find alternative forms of research therapy, especially in the United States, and,
suitable to the arts in clinical practice. Some even when music therapists are not available
believe that the study of music therapy (Cook 1981), has championed its use as an
provides an opportunity to develop expres- important nursing intervention (Cook 1986;
sive quality-of-life measures for people with Fletcher 1986; Frandsen 1989; Frank 1985;
serious illnesses, measures that are not solely Glynn 1986; Grimm & Pefley 1990; Keegan
based on verbal reporting (Aldridge 1989c; 1989; Kolkmeier 1989; Marchette, Main &
Aldridge 1991a). Redick 1989; Moss 1987; Mullooly, Levin &
-

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Feldman 1988; Prinsley 1986; Rice 1989; If music can influence physiological
Sammons 1984; Updike 1990; Walter 1983). At
the same time little work has been published
conditions like heart rate or blood
about the benefits of music therapy in general pressure in healthy people, then
medicine. The overall expectation is that the perhaps i t can be used therapeuti-
recreational, emotional, and physical health cally t o help patients with heart
of the patient is improved (Goloff 1981).
disease or hypertension.

Music, t h e H e a r t ,
and Respiration
marked, effect in the least musical groups. In
To explore the specific physiological effects general, listening to music was accompanied
of music, we begin with the effects of music by a fall in blood pressure when the music
on heart rate and blood pressure in healthy began. However, during the music, blood
people. If music can influence such physio- pressure rose slightly in correlation with
logical parameters in healthy individuals, the changes in melody, rhythm, pitch, and vol-
findings would support the possibility that ume, according to the musical susceptibility
music can be used therapeutically for patients of the listener. .
who have problems with heart disease or
hypertension. As we consider studies in this M o r e recently, in 1972, a valuable
area, we shall be led to examine the different paper by Bason and Celler (1972) found that
conceptualizations of time and their possible the human heart rate could be varied over
relation to health and disease. a certain range by synchronizing the sinus
The effects of music on the heart and rhythm-that is, the normal heart rhythm-
blood pressure have been a favorite theme with an external auditory stimulus. An au-
throughout history. We can trace the medical dible click was played to the subject at a pre-
study of such effects to an early issue of The cise time in the cardiac cycle. When the click
Lancet. In 1929, two researchers (Vincent & occurred within a certain range of the cycle,
Thompson 1929) made an attempt to discover the heart rate could be increased or decreased
the effect on blood pressure of listening to up to 12 percent in a period of 3 minutes or
music on the gramophone and radio. Subjects less. Fluctuations in heart rate caused by
were divided into "musical," "moderately breathing remained, but these tended to be
musical," and "nonmusical" groups. The cri- less when the heart was entrained with the
teria for musicality were not defined, except audible stimulus. When the click was not
to mention that the ideal "musical" group within the appropriate range of the cardiac
were "interested amateurs of good taste and cycle, no change would occur. Bason's paper
emotional susceptibility, who can, and hab- is important for supporting the proposition
itually do, enjoy music in a naive manner often made by music therapists that meeting
without the exercise of too much critical the tempo of the patient is the initial key to
f.iculty." therapeutic change.
People with varying degrees of musical An extension of this premise, that mu-
competence responded differently to volume, sical rhythm is a pacemaker, was investigated
melody, rhythm, pitch, and type of music. by Haas and her colleagues (Haas, Distenfeld
Melody produced the most marked effect. & Axen 1986). In this study, the researchers
When the music began, a rapid fall in blood examined the effects of musical rhythm on the
pressure occurred in the "musical" subjects. respiratory pattern, a pattern that serves both
However, during the music, a change in metabolic and behavioral functions. Meta-
melody, particularly if the music was soft, bolic respiratory pathways are located in the
resulted in a rise in blood pressure. Volume lower pons and medulla, whereas the behav-
also produced an apparent, although less ioral respiratory pathways are located mainly

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in the limbic forebrain structures which lead nied by a musical rhythm similar to the
to vocalization and complex behavior. There rhythm of the subjects' normal heart rate
appear to be so-called pattern generators in (Safranek, Koshland & Raymond 1982); that
the brain and spinal cord capable of synchro- respiratory rhythm follows the rhythm of
nizing metabolic and locomotor activity, music within certain limits of variability
thereby reinforcing an underlying uncon- (Diserens 1920); and that, perhaps most
scious rhythmic relationship between the two. intriguingly, there is a relationship between
Because there are metabolic conse- disturbed functional cardiac a r r h y t h m i a s
quences of active music making inseparable with disturbed respiration-and musical
from neural activity, the researchers chose rhythmic ability (Richter & Kayser 1991).
listening to music as the stimulus condition.
Haas hypothesized that the external musical I n the last study, the researchers
activity would have a direct influence as a Kayser and Richter hypothesized that patients
pacemaker on respiratory patterns but would with cardiac arrhythmias perform worse in
have only minimal effect in itself on metabolic perceiving and producing rhythm than do
changes and afferent stimuli-that is, would healthy controls. Thirty-one patients with
not induce any gross motor movements. functional cardiac arrhythmias were com-
pared with 31 control subjects. Subjects were
Twenty subjects were involved in this required to mark on a sheet of paper rhythmic
experiment. Four were experienced and patterns played for them on a tape recorder,
practicing musicians, six had formal musical and to tap synchronously with repeating
training but no longer played a musical in- patterns on the tape recorder. Patients with
strument, and the remaining ten had no dysrhythmias had significantly poorer abil-
musical training. The subjects first listened ities in musical perception and rhythmic
to a metronome set at 60 beats per minute anticipation than healthy controls. Patients
and tapped to that beat on a microphone after with a rapidly beating heart (tachycardia)
a baseline period. The subjects were then showed a particularly poor sense of rhythm
randomly presented five stimulus conditions: perception and synchronization.
four musical excerpts to which they also t a p
ped along, and one period of silence. Respira- Time and the Musical
tory data, including respiration frequency and
airflow volume, were collected, along with
Expression of Disease
heart rate and carbon dioxide released at the Studies such as this support the hypothesis
end of the breath, to measure gross metabolic that people with disease may perceive, and
changes and chemical respiratory drive. respond to, music differently than do healthy
The researchers found no appreciable people. It may be that different diseases dif-
changes in heart rate during the experiment ferently affect the responses we have to
indicating metabolic changes. But they also music. If we consider our human biology in
found that breathing was coordinated with terms of musical form rather than mechanical
the musical rhythm, expressed in the finger construction and our response to biological
tapping. For nonmusically trained subjects challenge as a repertoire of improvisations,
there was little coordination between breath- we can view disease as a restriction of our
ing and musical rhythm, while for trained abilities to improvise new solutions to chal-
musicians there was a tighter coupling of lenges-in musical terms, a restriction of our
breathing and rhythm. The Haas study, then, abilities to play improvised music (Aldridge
suggests that motor activity-finger tapping 1989a, Aldridge 1991~).
here-and respiration can be synchronized In regard to heart disease, for example,
by an external musical rhythm. it is entirely possible to describe the differ-
This finding fits related findings in ences in Type A and Type B behavior in
other studies-that muscle activity decreases musical language, suggesting that the Type
when one performs a motor task accompa- A behavior, said to constitute a risk factor for

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Table 1
Musical Elements in Contrasting Characteristics of Type A and B Behavior

Type A Behavior Type B Behavior Musical Components

increased voice volume voice quieter volume


fast speech rate slower speech rate tempo
short response latency longer response latency phrasing
emphatic voice less emphasis expression/articulation
hard metallic voice melodic voice timbre
less mutuality increased mutuality musical relationship
trying to keep control less need for control musical relationship
increased reactivity moderate reactivity responsive
increased heart rate decreased heart rate tempo
higher cardiovascular cardiovascular arousal dynamic
arousal maintained returns to lower level

The table lists the contrasting characteristics of Type A and B behavior end then identifies the musical
element that one could ascribe to such characteristics. Is the behavioral disturbance of heart disease
something like a disruption of musical patterns? Could music therapy be used to help
regulate such disturbances?

heart disease, may express a repertoire of and the actions of many individuals regu-
body response which is "musically limited." lated. In this form, deadlines have to be met,
Table 1 identifies the musical components in the passage of time is linear, and its measure-
the contrasting traits that distinguish Type A ment is quantitative. This is time as chronos,
and B behavior. and the concept is contained in the idea of
The Type A behavior pattern has been chronic illness.
characterized as an expression of the way in However, there is an alternative con-
which an individual responds to, and pro- ccptualization of time that is personal rather
vokes, environmental demands. Helman than public. This is time as hiros. It is poly-
(1987) refers to this view of the cause of heart chronic, and closer to the emerging biological
disease as a cultural construction that in- understanding of physiological times that are
volves the "unique social and symbolic char- rhythmically entrained (Johnson 19861, not to
acteristics of Western time." In this view, we an external clock, but to the person as a whole
are "the embodiment (both literally and figur- organism. In this conceptualization, time is
atively) of the values o f . . . Western society." in a state of flux; it is concerned with flexibil-
The individual is caught in the contradictions ity and the convergence of multiple tasks.
of selfdemand and societal demand, which Time is seen as springing from the self. We
for some people may become pathogenic. may have to consider the idea of heart disease
At the center of this cultural construc- as a kairotic illness where personal biological
tion is the notion of time. The predominant time is out of step with external imposed
form of Western time is monochronic. Time time.
is conceived as an external order imposed on Some authors do indeed suggest that
the individual. Such a view developed from when we try to impose a fusion between
the need of a modem industrialized society external clock time and personal physiologi-
to have a universal public order by which the cal time, our physiology is affected (Dossey
means of production could be coordinated 1982, Helman 1987). Helman writes:

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Western society is unique in trying to 1983; Lengdobler & Kiessling 1989; Schmut-
impose a fusion between clock time and termayer 1983; Standley 1986; Zimmerrnan
individual physiology-between rates
of bodily movement, speech, gestures, et al. 1989).
heartbeat, and respiration-and the A hospital situation fraught with anxi-
small machine strapped to the wrist or ety for the patient is the intensive care unit.
hung on the wall. "Rush hour," dead- For patients who have suffered a heart attack,
lines, diaries, appointments, and time-
tables all affect the physiology of modem and whose heart rhythms are potentially
[people], and help construct hidher unstable, the setting of the coronary care unit
world view and sense of identity. is itself likely to be anxiety provoking, an
experience that may reinforce the physiologi-
In music therapy there are possibilities cal and psychological reactions that initially
to experience these varying aspects of time led to the cardiac distress of the patient.
as they converge in their seamless reality. Several authors have assessed the use
The tension between personal and public of tape-recorded music delivered through
time may be heard when improvised music headphones to reduce anxiety and so reduce
is played in music therapy. Apart from stim- stress (Updike 1990) in patients in intensive
ulating experiences that differentiate and or coronary care clinics. Bonny has identified
develop those conceptualizations, music ther- a series of musical selections for tape record-
apy may promote an experience of a timeless ings that she believes has sedative effects
qualitative reality essential in particular to (Bonny 1983; Bonny & McCarron 1984; Bon-
the recovery of patients with heart disease. ny 1975) and also selections that can induce
relaxation and help the patient engage in
imagery (Bonny 1978),but none of these
Relieving Anxiety and Stress assertions has been empirically confirmed.
in Cardiac Patients However, Updike (19901, in an observational
study, supports Bonny's impression that there
Now we turn to the direct use of music in is a decreased systolic blood pressure, and a
coronary care.* beneficial mood change from anxiety to
Several authors have investigated the relaxed calm, when sedative music is played.
relationship between heart rate and anxiety
in the settings both of hospital care (Bolwerk Davis-~ollans(Davis-Rollans & Cun-
1990; Bonny 1983; Davis-Rollans & Cunning- ningham 1987) describes the effect of a 37-
ham 1987; Gross & Swartz 1982; Guzzetta minute tape of selected classical music on the
1989; Philip 1989; Wein 1987; Zimmerman, heart rate and rhythm of 24 coronary care unit
Pierson & Marker 1988) and of dentistry patients. (The selections consisted of the first
(Lehnen 1988).The intent usually has been to movement of Beethoven's Symphony No. 6,
reduce anxiety in chronically ill patients or to the first and fourth movements of Mozart's
treat anxiety in general (Chetta 1981; Daub & Eine klein Nachtmusik, and Smetana's The
Kirschner-Hermanns 1988; Fagen 1982; Gross Moldau.) Twelve of the patients had had heart
& Swartz 1982; Heyde & von Langsdorff attacks and another 12 had a chronic heart
condition. Patients were exposed to two ran-
domly varied &?-minuteperiods of continu-
*The relationshipbetween listening to music and ous monitoring, one period with music
changes in respiration has been investigated in delivered through headphones, the other a
various situations other than coronary care- control period without music during which
with college-student subjects (Formby et al. 19871,
psychotherapy patients (Fried 19901, various the background noise of the unit was heard
chronic illness groups undergoing group psycho- through the headphones. The heart-attack and
therapy (Gross & Swartz 1982), orthopaedic and chronic-heart-condition patients showed no
abdominal surgery patients (Lehmann, Horrichs differences. Eight patients reported a signifi-
& Hoeckle 1985), chronic lung disease patients
(Tiep et al. 1986), and in a study of mental stress cant change to a happier emotional state after
and exercise (Brody 1988). listening to the music (a result replicated in

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Figure 1
Emotional State of 24 Cardiac Patients Before and After Listening to Music Selections
(12 patients with heart attacks, 12 with chronic heart conditions)

tranquil happy worried sentimental sad both happy, other


satisfied romantic depressed satisfied and
tranquil

The shifts in feelings occurred from listening to music over headphones. There were no significant
differences between the responses of the patients who had heart attacks and the patients who had
chronic heart conditions. No changes in feelings were produced by the control intervention of
listening to the background noise of the coronary care unit over headphones.

Updike's observational study [Updike 1990]), tional music defined as "compositions having
although there were no significant changes in no vocalization or meter, periods of silence,
specific physiological variables during the and an asymmetric rhythm"). Stress was
music periods. Relevant here is the argument evaluated by peak (apical) heart rates, periph-
bv Cassem and Hackett (1971) that relieving eral temperatures (low in cardiac patients),
depression is beneficial to the overall status of cardiac complications, and qualitative data.
coronary care patients. Figure 1 displays the
various emotional shifts in the patients that T h e data revealed that lower apical
appeared after listening to the music. heart rates and raised peripheral tempera-
A study by Guzzetta (1989) sought to tures occurred more often in the relaxation
determine whether relaxation and music were and music therapy groups than in the control
effective in reducing stress in patients admit- group. The incidence of cardiac complications
ted to a coronary care unit with the presump- was also lower in the intervention groups.
tive diagnosis of acute myocardial infarction. Finally, most intervention subjects believed
In this experimental study, 80 patients were that such therapy was helpful. Thus, both
randomly assigned to a relaxation, music relaxation and music therapy were found to
therapy, or control group. The relaxation and be effective modalities of reducing stress in
music therapy groups participated in three these patients, with the combination of relax-
sessions over a two-day period. The relax- ation and music listening more effective than
ation group received a tape-recorded relax- relaxation alone. It should be noted further
ation induction. The music therapy group that apical heart rates were lowered in re-
received the relaxation induction and a 20- sponse to music over a series of sessions, thus
minute musical tape selected from three alter- supporting the argument that the effect of
native musical styles (soothing classical music therapy on physiological parameters
music, soothing popular music, and nontradi- occurs over time, and is therefore adaptive.

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The positive finding of this study is in reasons for this overall reduction in anxiety
contrast to the failure of Zimmerman and may have been that after four days the
I
colleagues (Zimmennan, Pierson & Marker situation had become less acute, the setting
1988) to find an influence of music on heart had become more familiar, and the fact that
rate, peripheral temperature, blood pressure, , by then a diagnosis had been confirmed.
or anxiety. However, Zimmerrnan's study In all these studies patients listened to
allowed for only one intervention of music. , music (or other sounds), and in thiscontext it
is relevant to recall the different possibilities
Zimmennan examined the effects of suggested by earlier-noted studies in which
listening to relaxation-type music and focused people in effect become the music makers.
on self-reported anxiety and on selected phys- , In the study by Bason and Celler (1972), the
iologic indices of relaxation in patients with researchers influenced heart rate by first
suspected myocardial infarction. Seventy-five , matching the heart rates of their subjects with
patients were randomly assigned to one of a musical rhythm. This finding suggests that
two experimental groups-one group listened in studies on the influences of music on heart
to taped music over headphones, the other to ' rate, the music should match the individual
"white noisef'*-or to a control group. The patient. Matching also makes psychological
Spielberger State Anxiety Inventory (Spiel- sense, since different people have varied reac-
berger 1983) was administered before and tions to the same music. Further, because
after each testing session, and blood pressure, improvised music necessarily "meets" the
heart rate, and digital skin temperatures were tempo of the patient, it may be that such
measured at baseline and at 10-minute inter- playing will have a larger impact than does
vals for the 30-minute session. The study "passive" listening to music.
revealed no significant difference among the The finding of Haas and colleagues
three groups in state anxiety scores or phys- (19861, that listening coupled with tapping
iologic parameters. Analyses were then con- synchronizes respiration pattern with music
ducted of the combined experimental groups rhythm, additionally suggests that active
and showed that significant improvement music playing can be used to influence
occurred in all of the physiologic parameters. physiological parameters and that this syn-
This finding reinforces the benefit of rest and chronization can easily be developed (Ald-
careful monitoring of patients in the coronary ridge 1989a).
care unit, but adds little to the understanding
of music interventions.
Bolwerk (1990) set out to relieve the Cancer Therapy, Pain
state anxiety of patients in a myocardial in-
farction ward using recorded classical music
Management,
(Bach's Largo, Beethoven's Largo, Debussy's and Hospice Care
Prelude to the Afternoon of a Faun). Forty adults
were randomly assigned to two equal groups, Cancer and chronic pain can require com-
one of which listened to relaxing music plex coordinated resources that are not only
during the first four days of hospitalization, medical but also psychological, social, and
the other of which received no music. There communal (Aldridge 1988; Coyle 1987; Fagen
was no controlled "silent condition." While , 1982; Frampton 1986; Frampton 1989; Gilbert
there was a significant reduction in state anxi- I 1977; Heyde & von Langsdorff 1983; Walter
ety in the treatment group, state anxiety also 1983). Hospice care in the United States and
fell comparably in the control group. The England has similarly attempted to meet the
need for the varied palliative and supportive
services that provide physical, psychological,
"White noise" or "synthetic silence" is an attempt and spiritual care for dying persons and their
to block out environmental noise. In this case it was families (Aldridge 1988; Coyle 1987; Framp-
a tape recording of sea sounds, which themselves l

were rhythmic (Philip 1989; Zimmennan 1989). ton 1986; Heyde & von Langsdorff 1983; Jacob

24 ADVANCES, The Journalof Mind-Body Health Vol. 9, No. 1 Winter 1993


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David Aldridge Collected music therapy papers 8


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1986). In all these settings, supportive services In a study of chronic pain, patients
are based upon an interdisciplinary team of playing self-selected tape-recorded
health care professionals and volunteers.
Music therapy is sometimes included music reported not only a reduction
in such services. in the emotional experience of
In the Supportive Care Program of the suffering but also a reduction in
Pain Service to the Neurology Department the actual sensation of pain.
of Sloan-Kettering Cancer Center, New York,
a music therapist was part of the supportive
team along with a psychiatrist, nurse-clini-
aan, neuro-oncologist, chaplain, and social
worker (Bailey 1983; Coyle 1987). Music actual physical sensation of pain, according to
therapy was used to promote relaxation, to the patients, was also reduced. This would
reduce anxiety, to supplement other pain appear to confound the common belief that
control methods, and to enhance commu- music therapy primarily induces qualitative
nication between patient and family (Bailey emotional experiences and to support the
1983,1984,1985). Depression was a common contention that music therapy can have a
feature of the patients in the program, and direct influence upon sensory parameters.
music therapy was thought to relieve this
state and enhance the patient's quality of life. , In addition to reducing pain, particu-
A better researched phenomenon is larly in pain clinics (Godley 1987; Locsin 1981;
the use of music to control chronic cancer I
Wolfe 19781, music has been offered during
pain, in studies that usually favor tape- chemotherapy as a form of relaxation and
recorded interventions rather than the ele- distraction (Kammrath 1989) to bring overall
ment of live performance. Combinations of 1 relief (Kerkvliet 1990) and to reduce nausea
pharmacological and nonpharmacological and vomiting (Frank 1985). Using taped
pain management are acceptable in modem music and guided imagery in combination
medicine (McCaffery 1990), with nonphar- with pharmacological antiemetics, Frank
macological interventions generally being (1985) found that state anxiety was signifi-
used as a form of distraction. cantly reduced, resulting in less vomiting
, even though the experience of nausea re-
This is the approach of a study by I
mained the same. Although Frank's study
Zimmerman and colleagues (Zimmerman, was not controlled, leading to the possibility
Pozehl, Duncan & Schmitz 1989) who inves- 8 that the reduced anxiety may have been due
tigated whether playing self-selected taped to the natural fall in anxiety levels at the end
music combined with suggestions of relax- 1 of a chemotherapy treatment, the study
ation, affected patients suffering with chronic 1 consisted of patients who had previously
pain. The study sought to determine from , experienced chemotherapy and who were
self-reports whether the music provided 1 conditioned to experience nausea or vomiting
additional relief to patients receiving pain 1 in conjunction with chemotherapy. That the
medication. In both the experimental and the subjects of the study felt relief and vomited
control groups, the blood level of analgesic less is an encouraging sign in the use of music
was controlled. Music was found to decrease 1 therapy in minimizing the distressing effects
the overall level of the pain experience as 1 of chemotherapy.
reported by patients randomly assigned to the l In the control of pain, time to listen,
music treatment group. Furthermore, there ,l separated from the surrounding influence of
was a significant reduction in the sensory, as
well as the affective, component of the pain as
' I the hospital unit by the use of headphones,
may itself be an important intervention. This
measured by the McGill Pain Questionnaire may be the underlying import of a study by
(Melzack 1975)-that is, not only was suffer- 1
l
Rider (1985) who found that perceived pain
ing as an emotional experience reduced, the 1 was reduced in a hospital situation in re-

ADVANCES, The Journal of Mind-Body Health Vol. 9, N o 1 Winter 1993


- -.- . - - - - - . . 25

David Aldridge Collected music therapy papers 9


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Music appears t o be a key in helping I In infants the ability to reciprocate the com-
munication of another person is an important
patients w i t h seemingly hopeless I
element in communicative competence (Mur-
neurological devastation regain ray & Trevarthen 1986; Street & Cappella
their "lost" language capabilities. 19891and is vital in acquiring speech (Glenn
& Cunningham 1984). Music therapy strate-
1 gies for neurologically damaged adults
I

sponse to classical music delivered through attempt to utilize the same processes of re-
headphones. It could be concluded from ciprocation with the expectation that they
will stimulate those brain functions that sup-
his work that isolation from environmental
sounds, canceling out external noise, has a port, precede, and extend functional speech
positive benefit for the patient regardless of
I
recovery, for these brain functions are essen-
inner content, whether the alternative is tially musical and rely upon brain plasticity.
music, relaxation induction, or silence. Combined with the ability to enhance
word retrieval, music can be used to improve
breath capacity, encourage respiration-phon-
ation patterns, correct articulation errors
Neurological Problems caused by inappropriate rhythm or speed,
Neurological diseases often result in physical and prepare the patient for articulatory move-
and/or mental impairment, and in many ments. In this sense music offers a sense of
cases their abrupt appearance are traumatic time which is not chronological, which is not
for the patient and his or her family (Jochims accessible to measurement, and which is vital
1990). Music appears to be a key in recovering in the coordination of human communication
former capabilities, language capabilities (Aldridge 1989a; Aldridge 1991~).
especially, in what at first can seem like Jacome (1984) tells of a stroke patient
hopeless neurological devastation (Aldridge who was dysfluent and had difficulty finding
1991b; Jones 1990; Sacks 1986). words. Yet, he writes, the patient
frequently whistled instead of attempting
For some patients with brain damage to answer with phonemes.. . he spon-
following head trauma, the problem may be taneously sang Spanish songs without
prompting with excellent pitch, melody,
the temporary loss of speech (aphasia). Music rhythm, lyrics, and emotional intonation.
therapy can play a valuable role helping a He could tap, hum, whistle, and sing
person regain his or her speech (Lucia 1987). along. . . . Emotional intonation of speech
Melodic Intonation Therapy has been devel- [prosody], spontaneous facial emotional
expression, gesturing, and pantomirnia
oped to fulfil1 such a rehabilitative role were exaggerated.
(Naeser & Helm-Estabrooks 1985; 0'Boyle &
Sanford 1988).This therapy involves embed- From this case study Jacome goes on
ding short propositional sentences into sim- to recommend that singing and musicality
ple, often repeated, melody patterns to which in aphasics be tested by clinicians, which
patients tap their fingers. Changes of inflec- Morgan recommended in a case of aphasia
tion, pitch, and rhythm in the melodies are 1 following stroke (Morgan & Tilluckdharry
selected to parallel what would be the natural 1982)
speech prosody of the chosen sentence. l Evidence of the possible global strategy
The therapy stimulates articulation, 1 of music processing in the brain-the possi-
fluency, and the shaping procedures of lan- bility that both brain hemispheres are in-
guage, all of which are akin to musical volved in this processing-is found in the
phrasing, and this encourages the singing of clinical literature. For example, in reporting
i
familiar songs. Singing within a context of I on two cases of aphasia, Morgan and ~ i l l u c k i
communication motivates a patient to com-
municate and thus promotes, it is hypoth-
, dharry (1982) describe spontaneous singing
by the patients as a welcome release from the
esized, the act of intentional verbal behavior. 1 helplessness of being a patient. The authors
26 ADVANCES, Thie Journal of Mind-Body Health Vol. 9,No.1 Winter 1993
-. . . .. .-.--

David Aldridge Collected music therapy papers 10


ALDRIDGE

hypothesized that singing was a means to The responsiveness t o music of


communicate thoughts externally which patients w i t h Alzheimer's disease
could not be articulated vocally in speech.
Although the "newer aspect" of speech was is a remarkable phenomenon.
lost in the damage of the dominant hemi-
sphere for language, the older function of
music was retained, possibly because music is changes in consciousness which are both
a function distributed over both hemispheres. measurable on a coma rating scale and appar-
Berman (1981) suggests that recovery ent to the eye of the clinician.
from aphasia is not a matter of new learning
by the nondominant hemisphere but a taking
over of responsibility for language by that Problems of the Elderly
hemisphere. The nondominant hemisphere
may be a "reserve" of functions available in The psychosocial rehabilitation of older per-
case of regional failure, indicating an overall sons is one of the main problems in health
brain plasticity (Naeser & Helm-Estabrooks policy (Haag 1985).About onequarter of the
1985).Similarly, language functions may over 65-year-olds face psychic problems, and
shift across hemispheres with multilinguals are without adequate treatment and rehabili-
as compared with monolinguals (Karanth tative care. The development of ambulatory,
& Rangamani 1988), or as a result of learning community-based services as well as inten-
and cultural exposure where music and lan- sive support for existing self-help efforts are
guage share common properties (Tsunoda clearly necessary. Music therapy has been
1983). suggested as a valuable part of a combined
treatment for the elderly (Dcllmann-Jenkins,
That singing is an activity correlated Papalia Finlay & Hennon 1984; Fenton &
with certain creative productive aspects of McRae 1989; Gilchrist & Calucy 1983; Gross
language may be an important point in this & Swartz 1982; Lehmann & Kirchner 1986;
context. An example is the case of a 2-year-old Morris 1986; Prinsley 1986; Rcnner 1986).
boy of above-average intelligence who expe-
rienced seizures, manifested by tic-like Music and Dementia in the Elderly
turning movements of the head (Herskowitz,
Rosman & Geschwind 1984). He induced At the age of 56 Maurice Ravel, the composer,
seizures, consistently, by his own singing but began to complain of increased fatigue and
not by listening to or imagining music, and lassitude. His condition deteriorated progres-
also induced them by his recitation and by sively (Henson 1988);and he lost the ability
his use of silly or witty language such as pun- to remember names, to speak spontaneously,
ning. (Seizure activity as registered on an and to write. While his mind, he reports, was
electroencephalogram correlated with clinical full of musical ideas, he could not set them
attacks and was present in both temporo- down (Dalessio 1984). Eventually his intel-
central regions, especially on the right side.) lectual functions and speech deteriorated
Aphasia is also found in elderly stroke until he could no longer recognize his
patients, and music therapy, as reported in music. In other words, he showed many of
case studies, has been used effectively in the features now associated with the condi-
combination with speech therapy to restore tion known as Alzheimer's disease.
speech (Lehmann & Kirchner 1986). The responsiveness of patients with
Gustorff and colleagues (Aldridge, Alzheimer's disease to music is a remarkable
Gustorff & Hannich 1990) describe the appli- phenomenon (Swartz et al. 1989). Despite the
cation of creative music therapy to coma language deterioration of such patients musi-
patients who were otherwise unresponsive. cal abilities appear to be preserved. Beatty
By matching her singing with the breathing and colleagues describe a woman who had
patterns of the patient, Gustorff stimulated severe aphasia, memory dysfunction, and

ADVANCES, The Journal of Mind-Body Health Vol. 9, No. 1 Winter 1993 27

David Aldridge Collected music therapy papers 11


ALDRIDGE

apraxia (an inability to perform intentional Breathing Training


movements), yet was able to read an unfamil-
iar song and perform on the xylophone, Fried (1990) presents a general overview of
which to her was an unconventional instru- the use of music in breathing training and
ment (Beatty et al. 1988). relaxation. Breathing training in itself is be-
In a case study Aldridge and Brandt lieved to have a physical benefit for anxious
(1991a) suggest that music therapy is an im- patients by enabling them to increase tidal
portant diagnostic tool in recognizing cogni- volume-the amount of air moved in a single
tive and motor impairment in the elderly, breath-without excessive loss of carbon
and a useful therapeutic adjunct in patient dioxide (hypocapnia). Typically, anxious pa-
care. Even though the patient they describe tients have relatively rapid shallow chest
may have been suffering from a pseudode- breathing and may hyperventilate.
mentia, the discussion further articulates the Music and breathing have been used
value of using music therapy for the treat- to induce alternate states of consciousness,
ment of the elderly, demented or depressed. and Fried's paper correlates the characteris-
Table 2, which draws on this discussion, tics of consciousness and the role of music in
compares the medical assessment of Alzhei- altering those states, reinforcing the findings
mer's disease with an assessment based on of McLellan (19881, who identifies the quali-
music therapy. ties of music which can be used to invoke
Certainly the anecdotal evidence sug- calm and inner peace.
gests that the quality of life of Alzheimer's Nursing approaches have also utilized
patients is significantly improved with music the anxiety-relieving effect of music in com-
therapy (Tyson 19891, accompanied by the bination with massage and breathing exer-
overall social benefits of acceptance and sense cises to relax patients, and to facilitate post-
of belonging gained by communicating with operative recovery (Keegan 1989).
others (Morris 1986). Prinsley (1986) recom-
mends music therapy for geriatric care, main- Anesthesia
taining that it reduces the use of tranquilizing
medication and reduces the use of hypnotics The ability of music to induce calm and well-
on the hospital ward and helps overall reha- being has also been used in general anesthe-
bilitation. He recommends that music therapy sia (Keegan 1989; McCluskey 1983). Patients
aim at specific treatment objectives: the social express their pleasure at awakening to music
goals of interaction and cooperation; the in the operating suite, the music having been
psychological goals of mood improvement played "openly" before the beginning of the
and self-expression; the intellectual goals of operation, and then through earphones
the stimulation of speech and organization of during the operation (Bonny & McCarron
mental processes; and the physical goals of 1984).
sensory stimulation and motor integration. In certain instances, it appears that
Such approaches also emphasize the benefit surgical patients are aware of the music being
of music programs for the professional carers played during an operation. In a study by
(Kartman 1984)and the families (Tyson 1989) Lehmann and colleagues (Lehmann, Homchs
of elderly patients. & Hoeckle 19851, patients undergoing elective
orthopaedic or lower abdominal surgery were
given either a placebo infusion (.9 percent
Assorted Findings sodium chloride) or the analgesic tramadol in
a randomized and double-blind manner, to
and Possibilities evaluate the efficacy of tramadol as one com-
A full examination of the possible use of ponent of balanced anesthesia. Postoperative
music therapy would cover a variety of only analgesic requirement and awareness of
partially explored areas. The following seem intraoperative events-tape-recorded music
to be the most important: offered via earphones-were further used to

28 ADVANCES, The Journal of Mind-Body Health Vol. 9, No. 1 Winter 1993

David Aldridge Collected music therapy papers 12


ALDRIDGE

Table 2
Comparison of Medical and Musical Assessments of Alzheirner's Disease

Medical Elements of Assessment Musical Elements of Assessment

continuing observation of mental continuing observation of mental


and functional status and functional status

testing of verbal skills, including testing of musical skills, including


speech fluency rhythm, melody, harmony, dynamic,
phrasing, articulation

cortical disorder testing: visuo-spatial skills cortical disorder testing: visuo-spatial


and ability to perform complex motor tasks skills and ability to perform complex
(including grip and right/left coordination) motor tasks (including grip and right/left
coordination)

testing for progressive memory testing for progressive memory


disintegration disintegration

motivation to complete tests, to achieve set motivation to sustain playing improvised


goals and persevere in set tasks music, to achieve musical goals and
persevere in maintaining musical form

"intention" difficult to assess; "intention" a feature of improvised


but considered important musical playing

concentration and attention span concentration on improvised playing


and attention to the instruments

flexibility in task switching flexibility in musical (including


instrumental) changes

mini-mental state score influenced ability to play improvised music


by educational status influenced by previous musical training

insensitive to small changes sensitive to small changes

ability to interpret surroundings ability to interpret musical context and


assessment of communication in the
therapeutic relationship

assess the effects of tramadol. Although Musical Hallucinations


anesthesia proved to be quite comparable in l

both groups, striking differences occurred Hallucinations may occur in any of our
with respect to intraoperative awareness: senses, and auditory hallucinations take
various forms-as voices, cries, noises, and,
while patients receiving placebo proved to be 1 rarely, music. However, the appearance of
amnesic, 65 percent of tramadol patients were
aware of intraoperative music. 1 musical hallucinations, often in elderly
patients, has generated interest in the medical
The ability to hear music during an
operation is also reported by Bonny (Bonny literature (Aizenberg, Schwartz & Modai
& McCarron 1984). 1 1986; Berries 1990; Fenton & McRae 1989;

ADVANCES, The Journal of Mind-Body Health Vol. 9, No. 1 Winter 1993 29

David Aldridge Collected music therapy papers 13


ALDRIDGE

How music therapy can be i n c o v o - of-the-ordinary experiences of women are


more often labeled pathologically.) Age, deaf-
rated into medical practice requires ness, and brain disease affecting the nondom-
extensive research studies. Unfortu- inant hemisphere played an important role in
nately, music therapists and their the development of hallucinations; on the
other hand, psychiatric illness and personality
medical colleagues have created factors were found to be unimportant. For
something of an impasse whereby these patients, the application of music ther-
apy to raise the ambient noise level, to orga-
each side demands a style of re- nize aural sensory input by giving it a musi-
search unacceptable t o the other. cal sense and thereby countering sensory
deprivation, and to stimulate and motivate
the patient seems a reasonable approach.

Gilchrist & Kalucy 1983; Hammere, McQuil- Immune Effects


len & Cohen 1983; McLoughlin 1990; Patel,
Keshavan & Martin 1987; Wengel, Burke & Work referring to the influence of music ther-
Holemon 1989). When such hallucinations do apy on immunological parameters is slim.
occur they are described as highly organized Lee (19911, who has written of the necessity
vocal or instrumental music. In contrast, the for working with HIV and AIDS patients,
ringing or other noises in the ears known as emphasizes the value of music therapy. How-
tinnitus is characterized by unformed sounds ever, Lee fails to be clear about clinical objec-
which sometimes may possess musical tives. There remains the possibility that
qualities (Wengel, Burke & Holemon 1989). immunological parameters may be influenced
by creatively improvising music. Research
T o some, case histories of patients with on this possibility should aim at linking
musical hallucinations suggest an underlying musical analyses with clinical information
psychiatric disorder (Aizenberg, Schwartz & about immune reactions such that therapeutic
Modai 1986; Wengel, Burke & Holemon 1989). correlations could be attempted (Aldridge
The hallucinations may be exacerbated by 1991b&c; Aldridge & Brandt 1991b; Aldridge,
dementia occurring with brain deterioration Brandt & Wohler 1989) and the results could
(Gilchrist & Kalucy 1983). Fenton and McRae be related to the current initiatives being
(1989) maintain that patients with musical made in psychoneuroimmunology.
hallucinations and hearing loss become anxi-
ous and depressed. Fenton challenges the
association of musical hallucination with Conclusion
psychosis and previous mental illness. His
explanation points to the degeneration of Music has the power to stimulate and to calm,
the aural end-organ whereby sensory input, to soothe and to inspire. Playing music un-
which ordinarily suppresses much nonessen- doubtedly benefits people. The elderly are
tial information, fails to inhibit information stimulated, the depressed are encouraged,
from other perception-bearing circuits. Other and the tired are invigorated. How music
investigators argue for a central brain dys- therapy can be incorporated into medical
function as evidenced by measures of brain practice requires extensive research studies.
function (Gilchrist & Kalucy 1983). Unfortunately, music therapists and their
In a study of 46 subjects with musical medical colleagues have created something
hallucinations (Berrios 19901, the hallucina- of an impasse whereby each side demands a
tions were far more common in females. style of research unacceptable to the other.
(The attribution of hallucinations to women We can hope that in our general search for
in particular should be regarded with a methods suitable for researching the human
degree of caution. As compared to men, out- condition (Aldridge 1991a1, we can find ways

30 ADVANCES, The Journalof Mind-Body Health Vol. 9, No. 1 Winter 1993

David Aldridge Collected music therapy papers 14


ALDRIDGE

Table 3
Comparison of Medical and Musical Assessments of Bowel Disease

Medical Elements of Assessment Musical Elements of Assessment


separation of self and "nonself" not tuned to oneself, uncoordinated

lack of gut motility lack of rhythmic flexibility, unresponsive


to tempo changes, lack of rhythmical
phrasing

increasingly introverted quiet playing with no personal contact


within the playing
- -

restricted in relationships difficult to contact in the musical


relationship

rigid repetitive playing, returning to the same


tempo and rhythmic pattern, unrespon-
sive to tempo changes
--

difficulty expressing feelings intolerant of particular harmonies

appears to be coping well with life in the appears to be going along with the music
face of internal turmoil but an underlying chaotic structure

dependent no initiatives within the music; dependent


upon the therapist

intractable to change difficult to treat, requiring many sessions

of working together in the future that will as art, religion, dream and the like, is
generate some flexibility in clinical research. necessarily pathogenic and destructive
of life; and that its virulence springs
As we have seen, some recent ap- specifically from the circumstances that
proaches have shown that the two vocabu- life depends upon interlocking circuits
laries of medicine and music have areas of of contingency, while consciousness can
only sec such short arcs of such circuits
commonality (Aldridge 1989a, 1991b&c; as human purpose may direct.
Aldridge & Brandt 1991a&b; Aldridge, Brandt
& Wohler 1989). One example of such com-
What we may have to consider is that
monality was illustrated earlier in Table 2, the human being is composed not as a ma-
which compares the medical and musical chine but rather as a piece of music which is
assessments of Alzheimer's disease. Table 3, improvised in the moment (Aldridge 1989b).
which compares the medical and musical From such a perspective we may search for
assessments of bowel disease, provides common themes among groups of individuals
another example. and identify particular repertoires of healthy
Gregory Bateson (1972) has reminded I
activities, but each person will have his or her
us of the need for the arts to accompany the own song. For those of us who are doctors,
science of modem medicine: our task is to encourage our patients in the
The point which I am trying to make in l
articulation of their individual singing. Per-
this paper is not an attack on medical haps in the future we will be encouraged to
science but a demonstration of an 1
inevitable fact: that merely purposive l understand how each one of us as a person
rationality unaided by such phenomena 1 can become our own work of art.

ADVANCES. The loumal of Mind-Body Health Vol. 9, No. l Winter 1993 31

David Aldridge Collected music therapy papers 15


ALDRIDGE

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David Aldridge Collected music therapy papers 19


The Arts in Psychotherapy, Vol. 18 pp. 59-64. Pergamon Press plc, 1991. Printed in the U.S.A.

PHYSIOLOGICAL CHANGE, COMMUNICATION, AND THE PLAYING OF


IMPROVISED MUSIC: SOME PROPOSALS FOR RESEARCH

DAVID ALDRIDGE, PhD*

Arms, hands, or legs do not behave; segmentals-these are time, phrasing, rhythm, pitch,
it is the total person who behaves and voice tone (which would more accurately be
(Condon, 1975, p. 45) called timbre). It is these qualities that are considered
by music therapists when they assess tape-recorded
In our music therapy research (Aldridge, 1988b; sessions of improvised music therapy.
Aldridge & Verney (1988) one of the areas we have The literature that first alerted us to these factors
considered is what happens when people improvise concerned chronic heart disease and Type A behavior
music together. Our intention is to be able to demon- (Dielman et al., 1987; Dimsdale, Stem, & Dillon,
strate to ourselves and other practitioners the influ- 1988; Friedmann, Thomas, Kulick-Ciuffo, Lynch, &
ence we believe music therapy has on the body of the Suginohara, 1982; Linden, 1987; Lynch, Long,
patient. We hope to demonstrate, in our later inves- Thomas, Malinow, & Katchor, 1981; Smith & Rhode-
tigations, the mutual relationship of physical changes wait, 1986). Heart disease patients were described in
in the therapist and patient during the process of terms that owed as much to a musical basis as they did
improvising music together. to a physiological process. Loud, fast speech using a
In trying to demonstrate this change we have limited range of voice timbre, and speech patterns that
looked for a simple physiological indicator. From a interrupted the responses of a partner, appeared to
preliminary review of the literature about communi- reflect qualities music therapists heard in their de-
cation, suitable indicators emerged from the studies of scriptions of patients when they creatively improvised
cardiovascular change. The principal measures in music (see Table 1). Although these qualitative de-
such work were those concerned with changes in scriptions may only be regarded as noise in the formal
blood pressure and heart rate. Heart rate was chosen terms of grammar, they provide the essential expres-
because it was a relatively easy parameter to observe sive context for communication.
and measure. Perhaps more significantly, it was a It seemed important to compare apparently similar
parameter acceptable to medical science with whom statements from two different theoretical backgrounds
we, as a therapeutic discipline, are attempting to to see if there was any commonality between them.
promote a dialogue. As heart disease is such an important problem in both
An earlier paper (Aldridge, 1988a) mentioned the mortality and morbidity throughout the Western world,
important factors associated with both biological form it made sense to propose h o w a discipline like
and musical form- time, phrasing, pitch, rhythm, improvised music therapy could offer a tool for both
and melodic contour. Similar considerations apply for assessment and treatment.
studies of communication. The basic preverbal fun- The medium of improvised music offers possibil-
damentals of human communication are called supra- ities for extremely varied communication and has a

*David Aldridge is research consultant to the Musiktherapie Abteilung, Universitat Witten Herdecke, Beckweg 4, D 5804 Herdecke (Ruhr),
West Germany.

David Aldridge Collected music therapy papers 20


DAVID ALDRIDGE

Table 1
Speech characteristics, physiological changes, and musical components

Type A behavior Type B behavior

increased voice volume voice quieter volume


fast speech rate slower speech rate tempo
short response latency longer response latency phrasing
emphatic voice less emphasis articulation
hardlmetallic voice melodic voice timbre
accelerated end of sentences
less mutuality increased mutuality relationship
try to keep control
increased reactivity
increased heart rate decreased heart rate
high cardiovascular arousal situational arousal
which is maintained returns to low level quickly
increased heart rate decreased heart rate

cognitive processing attention to the environment


more thoughts and words better performance of
recognition/perceptual tasks

subtlety beyond that of interview techniques that are At the center of this cultural construction (Helman,
confounded by verbal content. In addition, in impro- 1985) is the notion of time. The predominant form of
vised playing there is both the possibility of hearing Western time is monochronic. This form is conceived
what may be pathological in terms of restriction and as an external order imposed on the individual. It
inflexibility under challenge, and that which indicates developed from the need of a modem industrialized
positive possibilities for growth and change. This is society to have a universal public order by which the
accomplished by an essential feature of the therapy of means of production could be coordinated and the
performance. The patient is an active participant, not actions of many individuals regulated. In this form,
a passive recipient, in the process of assessment or deadlines have to be met, the passage of time is
therapy. linear, and its measurement is quantitative. This is
time as chronos.
However, there is an alternative conceptualization
Time
of time that is personal rather than public. This is time
A central, albeit contentious, area of coronary as kairos. It is polychronic, and closer to the emerg-
heart disease research has been that of Type A ing biological understanding of physiological times
behavior pattern, which is characterized by the way in that are rhythmically entrained (Johnson & Wood-
which an individual responds to, and provokes, envi- land-Hastings, 1986), not to an external clock, but to
ronmental demands. Helman (1987) refers to this the person as a whole organism. In this conceptual-
view of the cause of heart disease as a cultural ization, time is in a state of flux; it is concerned with
construction that involves the "unique social and flexibility and the convergence of multiple tasks.
symbolic characteristics of Western time" (p. 969). Time is seen as springing from the self.
In this view we are "the embodiment (both literally Apart from these notions, there is also the quali-
and figuratively) of the values of that society . . ." tatively different time encountered in ritual, in prayer,
(p. 971). The individual is caught in the contradic- and contemplation, during sex, or while dancing.
tions of self-demand and societal demand, which for Most are aware of the difference between an hour
some people may become pathogenic. spent in the company of a lover, which seems like

David Aldridge Collected music therapy papers 21


PHYSIOLOGICAL CHANGE, COMMUNICATION, AND PLAYING OF IMPROVISED MUSIC 61

minutes, and an hour spent in an administrative communication, principally talking, and elevations in
meeting, which can seem like days. blood pressure and heart rate. Reading out loud or
Some authors (Dossey, 1982; Helman, 1987) sug- talking to another person produced rapid and signifi-
gest that when we try to impose a fusion between cant rises in heart rate. From this work he suggested
external clock time and personal physiological time that certain hypertensive individuals experience diffi-
our physiology is affected. culties with communication, and that individual ele-
vations in blood pressure may be manifested symptoms
. . . Western society is unique in trying to impose a of difficulties with communication.
fusion between clock time and individual physiol- These communicational difficulties were then re-
ogy-between rates of bodily movement, speech, lated to the personality traits attributed, albeit conten-
gestures, heartbeat and respiration-and the small tiously, to Type A individuals with coronary heart
machine strapped to the wrist or hung on the wall. disease. Patients classified as Type A had been
'Rush hours,' deadlines, diaries, appointments and observed to speak fast, loud, have a tendency to
timetables all affect the physiology of modem man, interrupt, and use emphatic gestures. Friedman et al.,
and help construct his world view and sense of (1982) proposed that tempo and volume were impor-
identity. (Helman, 1987, p. 974)
tant characteristics of communication. Although tempo
and volume were correlated with cardiovascular change,
There may then be a tension between private and
this correlation was not dependent on the affective
public time resulting in stress and anxiety.
content of conversation and, therefore, independent
In music there are possibilities to experience these
of cognitive processes. This finding is important for
varying aspects of time as they converge in their
music therapists in the Nordoff-Robbins (1977) tradi-
seamless reality. The tension between personal and
tion who state that there is physical change during the
public time may be heard in improvised music and,
process of music therapy and that it is not necessary to
apart from promoting experiences that differentiate
use only a psychotherapeutic model for change in
and develop those conceptualizations, an experience
of a timeless qualitative reality can also be promoted. music therapy.
The recommendations of this earlv research for
When illness is categorized in Western medicine
patients with hypertension were to modify speech rate
the time concepts of acute and chronic are used. The
and volume using breathing techniques, and to control
presence of chronic illness is causing many problems
communication style. If cardiovascular response is a
for the delivery of health services throughout modem
process out of the range of conscious awareness, then
society and promoting a debate about the way in
presumably cognitive approaches are likely to be only
which such illness can be tackled in the latter part of
partial. Music therapy, with its intrinsic factors of
the twentieth century. However, it may be that
tempo and volume a s direct performance, may be
conceptualizations of illness to acute and chronic
dimension of a linear reality are limiting, and it may better suited to changing communicational style than
the so-called talking-therapies.
be necessary to consider a concept of kairotic illness.
A feature of assessing Type A behavior and
This illness may entail a personal attempt to maintain
physiological reactivity has been some form of assess-
identity in the face of imposed environmental con-
straints and would be similar to the way in which ment using an interview (Dimsdale, Stem, & Dillon,
1988). Unfortunately, these interviews have pre-
family therapists talk about personal solutions to a
sented a rather negative picture of the Type A person
problem located within an ecology of family mem-
as competitive, hard driving, ambitious, impatient,
bers, cultural constraint, and individual development
and often hostile. Yet, within these descriptions there
(Aldridge, 1988c; Bloch, 1987). These concepts of
are other categories of classification that are con-
time (development) and space (relationship) are fun-
cerned with elements of speech stylistics. These
damental to our culture whether it be in terms of
speech stylistics are easier to objectify and are less
science or art.
like personal value judgments. For our research
purposes they are also translatable into musical terms.
Cardiovascular Change and Communication Some researchers (Dielman et al., 1987; Linden,
1987; Siegman, Feldstein, Tomasso, Ringel, & Lat-
Lynch (Friedmann et al., 1982; Lynch et al., 1981) ing, 1987) recognize the following characteristics for
carefully explored the relationship between human assessing global Type A behavior:

David Aldridge Collected music therapy papers 22


DAVID ALDRIDGE

voice volume, voice; it also includes those gestures and movements


speed of speaking, that accompany vocal behavior. Condon (1975) calls
accelerated speech at the end of statements, these coordinated sounds and movements the quanta
 duration of silent pauses, of behavior or "linguistics-kinesics. "
 duration of subject's responses, In the playing of improvised music may be seen
 interruptiveand non-interruptivesimultaneous speech, how the person moves and also hear how the patient
response latency (the amount of time between the communicates nonverbally. It is this musico-kinesic
time the question is asked and the subject's an- behavior that contributes to the assessment of how a
swer), and person plays. A central feature of this assessment i$
voice timbre. the elusive quality of intentionality. The movement of
the body provides an indicator of whether the patient
These researchers also go on to assess interaction is playing with the therapist and intends to play the
patterns with the interviewer that they see as hostility instrument, or that the patient is just going along with
and verbal competitiveness. Verbal competitiveness the music. These kinesic considerations are also an
is "a tendency to take control of the interview away important indicator of self-synchrony within the per-
from the interviewer by interrupting, asking for un- son-either as bilateral synchrony (right and left hand
necessary qualifications, or raising the voice to drown playing together), or at the level of hearing and
out the interviewer's interruptions" (Dielman et al., responding to what is heard.
1987, p. 459). Music therapy, in the improvised sense used here,
These stylistic qualities and interactions can be is also dependent on the relationship between the
observed in musical improvisation, and without the patient and the therapist-an interactional synchrony.
need for negative connotations of hostility. In the It may be that a vital aspect of communication, which
context of a spoken interview it is important to is missed by some researchers, is not the ability to
remember that the content of some of the questions produce sound but the ability to listen and respond
may indeed be hostile or challenging. A further appropriately to sound. Smith and Rhodewalt (1986)
difficulty is that although speech rate and volume can consider this circular process of listening and re-
be measured, hostility, impatience, and competition sponding. They suggest an interactional understand-
can only be assessed subjectively with poor interrater ing where people with Type A behavior not only
reliability. respond in a certain way but also provoke situations
Speech variables have been significantly correlated that will allow them to respond in a characteristic
with coronary difficulties. These are: fashion.

 voice volume,
Heart Rate and Attention
voice emphasis,
 speed of speaking, While some researchers were studying the impli-
short response latency (Dielman et al., 1987), cations of heart rate and communication, others were
voice volume, studying the relationship between a process like
frequency of non-interruptive and interruptive si- attention, which is classically attributed to the brain,
multaneous speech (Siegman et al., 1987). and emotion, which is related to the body. This
mind-body unity debate heralded an era of interest in
These variables need not be discovered in a provoc- holistic medicine.
ative or challenging manner (Siegman et al., 1987). Sandman (1984a,b) began investigating the rela-
Short response latency and accelerated speech are also tionship between physiological responses and stress-
expressions of anxiety. ful, neutral, or pleasant stimuli. In particular he was
Music therapy can also offer a context for cornmu- interested in the apparent relationship between atten-
nication. It is not provocative in a hostile sense, and tion and emotion where attentional style could influ-
has the possibility to promote all the elements inher- ence physiological responses to affective stimuli. His
ent in speech stylistics without the confounding aspect work was based on the premise that the viscera, the
of affective components. These variables can be heard muscles, the heart, and the endocrine system provided
in a way that is not solely voice dependent. Commu- peripheral information to the brain and provided a
nication is not only concerned with the use of the context wherein perceptions gained meaning.

David Aldridge Collected music therapy papers 23


PHYSIOLOGICAL CHANGE, COMMUNICATION, AND PLAYING OF IMPROVISED MUSIC 63

In this approach there appeared to be two general view was also supported by indications that when
categories of attentional styles. One, field-indepen- heart rate decelerated, there was an increased blood
dent subjects, appeared to use bodily information flow to the brain. There appeared to be "a fortuitous
more readily than others and made accurate percep- or purposeful synchronization between physiological
tual judgments about the environment even though systems" Sandman, 1984b, p. 118), and it appeared
presented with distracting perceptual information. that the hemispheres of the brain were "tuned"
Such subjects appeared to have a broad and differen- (Sandman, 1984a; Walker & Sandman, 1979; Walker
tiated range of physiological responses to various & Sandman, 1982) by the cardiovascular system.
stimuli. For these subjects there was a concordance These findings challenged the classical view that
between how they said they felt and how they intellectual abilities were the sole province of the
responded physiologically. The other, field-depen- brain and promoted further investigations of links
dent subjects, tended to base their perceptual judg- between both mind and body where the cardiovascu-
ments on distracting external information, and used lar system influences the brain and behavior. In some
this external information to assess their own state. patients "an inviolable relationship exists between the
When reacting to stimuli they were less emotionally brain and the cardiovascular system that may be a
complex; rather than exhibiting a range of qualita- biological marker for psychiatric state" (Sandman,
tively different reactions they responded with differ- 1984a, p. 255).
ent levels of arousal. These researchers speculate that the heart has an
The implications for music therapy from these influence on consciousness or awareness. The impact
preliminary findings are that we may also hear such of heart rate is dynamic and fluctuates between
field dependent or independent characteristics in the suppressing and liberating the left and right sides of
musical playing of the patient. For example, some the brain. When heart rate increases, it is indicative of
patients may have an extensive repertoire of playing cognitive processing and a rejection of the environ-
styles and be able to play both rhythmically and ment; when heart rate decreases, there is a switch to
melodically while listening to themselves and to the environmental attention. The cardiovascular system
therapist in the overall context of the music. Yet reflects a person's intention to receive information. If
others may have a limited range of playing styles and, this is so, music therapy is a sensitive tool for
in response to changes in the music, may only change discerning the physiological state of a person as a
particular musical parameters (i.e., play louder or whole. This tool is not fragmented by introducing a
faster). measuring instrument between researcher and subject
We speculate that repertoires of coping responses that limits responses to a narrow mechanical range.
can be heard musically, and these reflect quantitative, We anticipate that we can hear how changes in the
differentiated physiological responses. It is this link improvised musical playing are reflected in changes
that we wish to demonstrate in our physiological in the heart rate of the patient. Hypotheses about a
experiments. Note that these observed patterns are patient listening only to him or herself and not
considered either musically or physiologically. We listening to another may be heard in their fast, or
are not necessarily invoking any descriptions of accelerating, heart rate.
psychological state. If, as is also inferred in this literature, intellectual
Sandman was to develop his work further. He was abilities are not solely begun and terminated in the
interested in the pronounced, and paradoxical, de- brain but are whole body phenomena, then the active
crease in heart rate of field-independent subjects in playing of the patient in music therapy is most
response to stressful information. He began to dem- important. The patient is involved physically in this
onstrate that a learned heart rate deceleration could therapy, is not expected to sit still and answer a
bring about an improved attention to the environment. questionnaire, or remain stationary while being mon-
Thus, he argued, by controlling heart rate, attention itored. He or she is asked to play. This improvised
could also be influenced. playing encourages the use of soma and psyche. To
Awareness of the environment was partially regu- play rhythmically is a whole-person activity. To play
lated by interactions of the brain and the heart. When rhythmically with another person is an extension of
heart rate was low, subjects perceived stimuli signif- this activity that includes vital components of rela-
icantly better than when heart rate was high. This tionship.

David Aldridge Collected music therapy papers 24


DAVID ALDRIDGE

Conclusion assessment of personal health. Proceedings of the First Znter-


national Conference of Cerebral Dominance. Munchen.
In creative music therapy lies the possibility to Aldridge, D. (1988b). Research in a hospital setting. Holistic
hear in a dynamic way the individual as a whole self Health, 18, 9-10.
as well as in relationship with another person. We can Aldridge, D. (1988~).Treating self-mutilatory behaviour: A social
strategy. Family Systems Medicine, 6, 5-19.
hear the person coming into being as he or she creates
Aldridge, D., & Verney, R. (1988). Creative music therapy in a
a relationship in time. In addition music therapy offers hospital setting: A preliminary research design. British Journal
individuals a chance to concretely experience the self of Music Therapy, 2, 1 4 1 7 .
in time, to literally hear their own self coming into Bloch, D. (1987). Familyldiseaseltreatment systems: A co-evolu-
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internal demands, then in the playing of improvised 37-56.
music may be heard the creative way in which a Dielman, T., Butchart, A., Moss, G., Harrison, R., Harlan, W., &
person meets those demands. It could be that illness is Horvath, W. (1987). Psychometric properties of component
a state where there is: (a) a restriction in the ability of and global measures of structured interview assessed Type A
behavior in a population sample. Psychosomatic Medicine, 49,
the person as a whole to improvise creatively (i.e., 458-469.
develop new solutions to problems), or (b) a limited Dimsdale, J., Stem, M., & Dillon, E. (1988). The stress interview
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By promoting creative coping responses we may Medicine, 50, 64-71.
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These are based on the creative qualities of the whole Suginohara, M. (1982). The effects of normal and rapid speech
person that promote autonomy. This catalyzation of on blood pressure. Psychosomatic Medicine, 44, 545-553.
self-healing properties is a central feature of the art of Helman, C. (1985). Psyche, soma and society: The social construc-
tion of psychosomatic disorders. Culture, Medicine and Psy-
medicine that can work in concert with the science of chiatry, 9, 1-26.
medicine. Helman, C. (1987). Heart disease and the cultural construction of
The videotape-recorded material of music therapy time: The type A behaviour pattern as a western culture-bound
and experimental session is the rudimentary vehicle syndrome. Social Science and Medicine, 25, 969-979.
for research development. Such recordings are rich in Johnson, C., & Woodland-Hastings, J. (1986). The elusive mech-
anism of the circadian clock. American Scientist, 74, 29-36.
visual and aural data. Not only can those acts that are Linden, W. (1987). A microanalysis of autonomic activity during
quantifiable be counted, but those phenomena that are human speech. Psychosomatic Medicine, 49, 562-578.
not amenable to counting but are qualitatively essen- Lynch, J., Long, M., Thomas, S., Malinow, K., & Katchor, A.
tial to health can also be experienced and described. (1981). The effects of talking on the blood pressure of hyper-
tensive and normotensive individuals. Psychosomatic Medi-
We may discover in this work that, in terms of cine, 43, 25-33.
biofeedback, the playing of improvised music offers Nordoff, P,, & Robbins, C. (1977). Creative music therapy. New
the subject an experience richer and more immediate York: John Day.
than the filtering of physiological parameters through Sandman, C. (1984a). Afferent influences on the cortical evoked
an external machine. In this way the person remains response. In M. Coles, J. Jennings, J. Stem (Eds.), Psycho-
physiological Perspectives: Festschrift for Beatrice and John
the supreme and sensitive instrument of his or her Lacey. Stroudberg PA: Hutchinson & Ross.
own understanding both literally and figuratively. The Sandman, C. (1984b). Augmentation of the auditory event related
next stage for formulating research studies is to potentials of the brain during diastole. International Journal of
observe and record the correlations between the heart Psychophysiology, 2, 111-1 19.
Siegman, A., Feldstein, S., Tomasso, C., Ringel, N., & Lating, J.
rates of subjects and the musical changes that occur (1987). Expressive vocal behavior and the severity of coronary
when they are playing improvised music. From these heart disease. Psychosomatic Medicine, 49, 545-561.
observations it should be possible to develop a means Smith, T. W., & Rhodewalt, F. (1986). States, traits and pro-
of demonstrating physiological change in the context cesses: A transactional alternative to the individual difference
of a musical relationship, and then go on to observe assumptions in Type A behavior and physiological reactivity.
Journal of Research in Personality, 20, 229-25 1.
particular patient populations to investigate links Walker, B., & Sandman, C. (1979). Human visual evoked re-
between improvised playing, physiological parame- sponses are related to heart rate. Journal of Comparative and
ters, and ill health. Physiological Psychology, 4, 7 17-729.
Walker, B., & Sandman, C. (1982). Visual evoked potentials
References change as heart rate and carotid pressure change. Psychophys-
iology, 19, 520-527.
Aldridge, D. (1988a). Music as identity: A contribution to the

David Aldridge Collected music therapy papers 25


The A r t s in P.syclior/~er(~pv.
Vol. 16 pp. 91-97. *" I'c~-g:imon Press plc. 1989. Printed in the U.S.A. 0197-4556189 $3.00 + .OO

A PHENOMENOLOGICAL COMPARISON OF THE ORGANIZATION OF MUSIC


AND THE SELF

DAVID ALDRIDGE, PhD*

This paper is concerned with an understanding most scientists would recognize here a gap in sci-
of musical perception and how it is linked with entific knowledge and would not want to deny the
the identity of the whole person. An extension of fact of a connection.
the understanding is the notion of being as it is
characterized by the tradition of phenomcnologi- The problem in understanding the perception
cal philosophy, which looks toward "being in the of music is inherent too in understanding per-
world" as a unified experience. sonal health. Health is complex, yet how is one
This phenomenological approach sees a corrc- to make a unified sense of the complexity that
lation between music form and biological form. avoids fragmentation and reduction? Furthcr-
By regarding the identity of a person as a musical more, how can one begin to understand qualita-
form that is continually being composed in the tive aspects of personal life as they are expressed
world, a surface appears on which to project our in terms of hope, joy, and beauty, which com-
understanding of a person as a physiological and plement increasingly sophisticated quantitative
psychological whole being. The thrust of this knowledge of the human body?
endeavor is to view people as "symphonic" Although there have been many attempts to
rather than "mechanic." By considering how describe the process underlying the perception of
persons come into the world as whole creative music there has been little success in presenting
beings one can speculate on their potential for any satisfactory explanation. The perception is
health and well-being. not limited solely by the acuity of the ear
(Longuet-Higgins, 1979) and all that impinges on
The Perception of Music the listener, but is achieved in combination with
the conceptual structure imposed by the listener.
As Dennis Fry (1971, p. 1) wrote, In this way the knowledge of the phenomenon is
intimately linked with the phenomenon itself.
In the case of music there is also continuously Both the knower and the known are part of the
interaction between the physical character of the same process. Perception in this sense is an
musical stimulus and its physiological and psycho- holistic strategy.
logical effects so that a more thorough study of Much scientific research into the perception of
music would demand at least the combining of a
physical, physiological and psychological ap- music has concentrated on those aspects that can
proach. Modern science has relatively little infor- be measured quantitatively. In this way nature is
mation about the links between physics, physiology organized according to the concepts that are im-
and psychology and is certainly not in a position to posed on it. This is the analytic mode of con-
specify how the effects are related in music, but sciousness that is predominantly a product of the

*David Aldridge is research consultant to the Musikthcrapicablcilnng, Univcrsitiits Witten Herdecke, D5084 West Germany.
1

91

David Aldridge Collected music therapy papers 26


92 DAVID ALDRIDGE

verbal intellectual mind (Burtoft , 1980) where give meaning to what is heard, an act of identity.
phenomena are represented by number, and var- However the nonsensory process of cognition is
iables in equations are represented by quantities. transparent, or rather silent, and appears as if
This paper attempts to dcmonstnite the need hearing were solely a sensory experience. The
for a phenomenological understanding tliat is process of discovery in science is also one of the
isomorphic with the medium of music itself. An perception of meaning. What appears to be em-
holistic consciousness that is qualitative, non- pirical is indeed cognitive.
verbal, and participatory appears in the very If the ohenomenon of music is considered as a
phenomenon of music. What is more, Hie cle- unified whole the question arises whether this
ment of participation by the knower spciiks di- unity is imposed on the senses by the mind, or
rectly to the aspect of music as performiincc, ; i n whether it is the phenomenon itself that is a
aspect that is sadly neglected by many reseiirc11- whole. To a great extent organizational frame-
ers who reduce research into the perception of works are imposed on experience; hence there
music to a restricted range of received sounds. are descri~tionsthat call for a framework of
Heidegger (1962) emphasized the intuitive reference in the perception of rhythm and of
element in the comprehension of phenomena. melody. However, there is a danger of being
When music is heard, the phenomenon becomes blinded to this imposed organization and thus to
its own explanation. It is that which shows itself believe that this is the way the phenomenon
in itself. Perhaps one can begin to understand really is.
people as they come into the world, as music, Once an attempt is made to synthetically re-
i.e., composed as a whole. produce the act of n~usical perception the
The explanatory idea of a Frame of Reference framework analogy is seen as limited. Lon-
is a common theme among a number of writers guet-Higgins' (1979, 1982) careful and inspiring
referring to musical perception and brain func- work demonstrates the utility of a frame of refer-
tion (Longuet-Higgins, 1979; Safranek, Kosh- ence approach using tempo and meter for the
land, & Raymond, 1982; Steedman, 1977; perception of rhythm. This approach fails, as he
Walker, 1979). Walker suggests an "Ursatz" (the remarks, when it is understood how a particular
essential underlying principle) to music thiitis aii choice of phrasing affects the rhythm. Further-
all-embracing thought unifying the music and giv- more, the perception of atonal and arhythmic
ing a musical structure accessible to analysis. music are still mysteries to analytical methods.
However, he also states that this musical struc- Yet one can hear and play arhythmically and
ture is ultimately unknowable (i.e., beyond atonally.
analysis). In this explanation lies the perennial However, there is an approach to understand-
difficulty of seeking a unifying explanation by an ing phenomena as unified wholes. The roots of
analysis into parts. Somehow that which is intui- this approach are in the work of Goethe's scien-
tively sought is lost in the process of description. tific consciousness and the work of Franz Bren-
What results is a statement that what is sought is tano (Bortol't, 1986). Both of these men were to
unknowable, rather than a questioning of the ana- be influential in the development of phenome-
lytic method of knowing. This situation also pre- nology. Goethe perceived the wholeness of the
vails in the understanding of personal health. phenomena not as imposed by the mind but by a
According to the philosophy of empiricism, conscious act of experience. This experience
knowledge of the world is gleaned through expe- could not be reduced to an intellectual construc-
rience. This knowledge comes through the tion in terms of the way the phenomena are or-
senses. However, there is more to this sensory ganized. Bortoft uses the following example to
knowledge than meets the ear. There is always a explain this change of consciousness:
nonsensory factor involved-that of cognitive
perception, the dimension of the mind. This . . . if we watch a bird flying across the sky and
cognitive perception is a process ol' organizittion put our attention into seeing flying, instead of
where meaning is imposed upon wh.11 is 1ie;iri.I. I n sccing a bird which flies (implying a separation
this way a seemingly nieaningless ground ol' between an entity 'bird' and an action 'flying'
sound is given meaning. To perceive tlien is lo which it performs), we can experience this in the

David Aldridge Collected music therapy papers 27


MUSIC AND T H E S E L F 93

mode of dynamical simultaneity as one whole primacy of the word in speech, and to understand
event. By plunging into seeingjlyit~gwe find that speech in terms of phrasing, rhythm, pitch, and
our attention expands to experience this moment melody, a different consciousness emerges. This
as one whole which is its own present moment. consciousness reflects a different range of logics
(P. 31) to the predicatory logic of language. Here are
dynamic, movement, interval, and time-the very
In this phenomenological approach sounds are essences of music and of biological function.
heard as sensory information and as a unified
I f consideration is given to what constitutes
experience, which is music as consciousness.
people as identity attention may be better di-
How then can personal health be perceived as ;I
rected to how they are composed not only in
unified experience? qiiii~i~i~i-dvc terms of bones and blood, but how
Iliey are composed as musical beings in regard to
Language as Music
relationship patterns, rhythms, and melodic con-
Whether or not music is a language is ;I riin- tours. This may reflect the original biblical notion
ning debate through the literallire I-dnliiig lo I he tlml in the beginning was "logos" (i.e., order). In
perception of music. Morley (1981) iusis1.s lli:il music lies the phenomenon of a person coming
.
music is a form of conin~unic;itioii ;in;iloi:oiis
. Io into order. It may perhaps be that when a sense
speech in that it has cadences :incl piincti~;i~iot~. ol' l liat order is lost a person experiences a loss of
Perhaps the restructuring of the primicy of l:in, 11:illh.
guage over music to suggest Ihiil lii~igii;igeis ; I
form of music may be more enlightening. I t could Hemispheric Processing
be that speech is analogous to music and lhiil I he
In support of the above argument, the realm of
musical components of speech are ;ibilicittecl in
cerebral processing and music perception may
favor of the literal content. ;ilso be examined. Although language processing
Most in academic life rarely question Hie pri-
may be dominant in one hemisphere of the brain,
macy of the word. As a form of conimunicu~ion
music processing involves an holistic under-
the word appears to be central to endeavor
standing of the interaction of both cerebral
whether written o r spoken. Underlying this con-
hemispheres (Altenmullcr, 1986; Brust, 1980;
cern with language is an analytical conscious-
Gates & Bradshaw, 1977).
ness. A subject-predicate gramnitir is used that
In attempting to understand the perception of
gives a structure to language. This very struc-
music there have been a number of investigations
ture, in turn, structures consciousness. l l is ;I
feature common to Western culture; in the be- into the hemispheric strategies involved. Much
ginning was "the word." To write that creittion ol' the literature considering musical perception
concentrates on the significance of hemispheric
beean with the "word" hides the fact thal the
.a
dominance. Gates and Bradshaw (1977) conclude
author is a writer whose consciousness is struc-
that cerebral hemispheres are concerned with
tured by the medium used.
music perception and that no laterality differ-
It might profitably be asked "How would a
cnces are apparent. Other authors (Wagner &
musician communicate this primal understanding
of consciousness? What is 'in the beginning' for a Hannon, 1981) suggest that two processing func-
musician?" In communicating in a different way tions develop with training where left and right
hemispheres are simultaneously involved, and
perhaps communication with a different con-
sciousness may take place. This understanding that musical stimuli are capable of eliciting both
may also explain the difficulty ofwriting and talk- right and left ear superiority (Kellar & Bever,
1980). Similarly, when people listen to and per-
ing about health using a verbal analytic language
form music they utilize differing hemispheric
when there is concern with a realm of bchavior
processing strategies.
necessitating an holistic mode of consciousness.
Perhaps an expression of health is something that
could better be sung or played.
To move from a position that advocates the Evidence of the global strategy of music pro-

David Aldridge Collected music therapy papers 28


cessing in the brain is found in the clinic;il literii- The rhythms and pulses that entrain the
ture. In two cases of aphasia (Moigan A 'I il- rhythmic patterns of the human body are non-
luckdharry, 1982) singing was M-CII ;is ;I wclconu- material. The senses-hearing, smell, taste,
release from the helplessness ofheiiq; i i p;itii.~i~t. sight, touch-in addition to balancing and mov-
The authors hypothesized thal singing w;is ; I ing are integrated as a musical form. It is rhythm
means to communicate thoughts externally. Al- that provides the ground of being, and a rhythm
though the "newer aspect" of speech was losi, of which being is generally unaware and that is
the older function of music was rcl;iincd, perhaps the gestalt of identity.
possibly because music is a function di~trihi~teil Dossey (1982) writes of disorders of time being
over both hemispheres. particularly prevalent in modern society. This
Berman (1981) suggests that recovery from may be rephrased as disorders of disrupted
aphasia is not a matter OS new learning by tin- rhythm. The work of Safranek et al. (1982)
nondominant hemisphere but a taking over of re- demonstrates that subjects use a preferred per-
sponsibility for language by that henlisphere. The sonal tempo in the performance of a motor task.
nondominant hemisphere may be a reserve of This personal tempo is reflected as a functional
functions in case of regional failure. A less de- reflex in the muscle. However, by introducing a
fensive alternative explanation is that the strat- n~usicalrhythm while a musical task is being per-
egies underlying musical proccss are those same formed, which is different from that of the per-
strategies underlying biological process and (lie sonal tempo of the subject, then a different re-
maintenance of the identity of the organism. sponse is invoked in the subject. The authors see
this as a "volitional response." Control over
seemingly involuntary movements can be
Rhythm
achieved by meeting the personal tempo of a sub-
Rhythm is the key to the integrativc process ject and thcn changing to a slower, even beat.
underlying both musical perception and physi- Meeting this tempo has been a central strategy in
ological coherence. Barfeld's ( 1978) approach hypnotherapy. The existence and role of a per-
suggests that when n~usicalform as tonal shape sonal tempo are refined even further in creative
meets the rhythm of breathing there is the niusi- music therapy (Nordoff & Robbins, 1977). It may
cal experience. External auditory activity is be inferred thcn that people become aware of the
mediated by internal perceptual shaping in the ground of their being not in verbal logic, but in a
context of a personal rhythm. It is interesting to logic analogous to the ground of their own func-
speculate here on the meaning of context, not as tioning (i.e., music). In this sense insight is had
a container but as coiz textere, which is a weaving about a person. not in a restricted verbal intellec-
together. One pattern is then woven against an- tual sense, but as being- in the world.
other to produce an interference pattern, the The frame of reference approach mentioned
basis for matter. Sound is woven together witli' e;irlier is used indirectly by Povel (1984) to
rhythm. understand rhythm. Tones in sequence are seen
When considering communication, rhythm is as having a dual function. They are characterized
fundamental to organization. Before any consid- by pitch, volume, timbre, and duration. They
eration of content one must connect rhythmically also mark points in time. These tones then
with another person and establish some com- produce both structure in time and of time. When
monality. This connection of rhythms is seen as tones are used in sequence only as temporal con-
the phenomenon of entrainment, which occurs in cepts they can be thought of as providing a tem-
the circadian rhythms of temperature and sleep. poral grid, which is a time scale on which the
Should they lose entrainment, then jet lag takes tone sequences can be mapped for duration and
place. Scientists observing such phenomena location. It might profitably be asked what the
often attempt to find an underlying mechanism isomorphic events in terms of physiology are that
for entrainment (Johnson & Woodland-Hastings, would meet such a dual function. There may be
1986), a master clock ils it were. However, when regular sequential pulses of metabolic, cardiac,
moving from a mechanical perspective a musical o r respiratory activity within the body that also
analogy for coordinating rhythm might be more have qualities of pitch, timbre, and duration.
appropriate. What is important in these descriptions of musi-

David Aldridge Collected music therapy papers 29


MUSIC A N 1) '1'1-l l< S171 , I T 95

cal perception is the emphasis on conlexl where


there are different levels of ;itlcntion ocenri i i i f ;
sin~ultaneously against a bachgromnl Iciiipoi ; I I Kliylhin too plays a role in the perception of
structure (Jones, Kidd, & Wct/x'I, 1981; Iiukl. iiirlnily. The perceptions of speech and music are
(01~iiidabletasks of pattern perception. The lis-
Boltz, & Jones, 1984).
Recent research in cardiology has eniph.isi/.cd I C I I V I hiis to extract meaning from lengthy se-
the relationship between changes in bre;itliii~g qiirin..cs of rapidly changing elements distributed
patterns, personal tempo, and hypertension. The in I ime (Morrongiello, Trehub, Thorpe, &
work of Lynch and his associates (I~iieilniiinn, I'oililupo, 1985).
Thomas, Kulick-Ciuffo, Lynch, & Suginoh;ira, Temporal predictability is important for track-
1982; Lynch, Long, Thomas, Malinov, & ing melody lines (Jones et al., 1981; Kidd et al.,
Katcher, 1981) has highlighted the link, between 1984). Kidd et al. also refer to melody as having a
hypertension and fast speaking. A feature of type sinicture in time and that a regular rhythm
A behavior in patients with hypertension is that acilitates the detection of a musical interval and
their blood pressure, which is alre;idy high, its subsequent integration into a cognitive repre-
shows an increase when they comniunic;ite. scnt;ition of the serial structure of the musical
Such patients are seen to have diffici11tie-i in ptitt ern. Adults identify familiar melodies on the
communication. They often appear disconnected basis of relational information about intervals be-
from their feelings and have an underlying sense twccn toncs rather than the absolute information
of hopelessness regal ding their ; h i l i t y lo corn- ol"p;irlicular tones. In the recognition of unfamil-
municate effectively. When people do not expect iar melodies, less precise information is gathered
to communicate effectively their blood pressure iihoul the tone itself. The primary concern is with
rises. Because they do not expect to be under- successive frequency changes o r melodic con-
stood they do not listen. By not listening they tour. The rhythmical context prepares the lis-
miss the chance to lower their blood pressure. tener in advance for the onset of certain musical
Attention to the environment (i.e., listening) is intervals and therefore a structure from which to
seen as promoting a deceleration in heart late discern, or predict, change.
and a decrease in blood pressurc. Yet, attention 'Die implication of this work is that change,
to the self is seen as promoting heart rale whether it be melody o r rhythm, is dependent on
(Sandman, 1984; Walker & Sandman, 1979, a global rhythmic strategy. To extend this un-
1982). Changes then in tempo, and the promotion derstanding to biological processes, it can be hy-
of listening o r sounding, will have implications pothesized that differences in contour (melody)
for cardiac and respiratory activity. Lynch et al. (as in the release of hormones, fluctuations in
(1981) suggest therapeutic activities to proniote a temperature) and changes in rhythm are detected
reduction in hypertension utilizing slow and deep in reference to a global rhythmic context of the
breathing. Playing improvised music as pure body. This global context may be regulated by
communication, with its absence of verbal con- the heart or breathing patterns, or may be an
tent and its primary component of rhythmic ac- emergent property of the varying rhythmic pat-
tivity related to personal tempo and volitional re- terns of the body. Disruption in this overall
sponsc (Safranek et al., 1982), may be the ideal global strategy will influence a person's ability to
medium for achieving such change. detect new or changed nontemporal information
It is important to introduce a word of caution (Cuddy, Cohen, & Miller, 1979; Jones e t al.,
here. The motor act of communicating is not the l98 1 ; Kidd et al., 1984). One may not be aware of
cause of the elevated blood pressure. Blood certain changes and become either out of tune o r
pressure is elevated whenever communication out of time.
takes place. The elevation points to a process
Conclusion
beyond the motor act, which is intent, a feature
also evident in change of muscle activity (Safran- The perception of music requires an holistic
ek et al., 1982). This switch from physiology strategy where the play of patterned frequencies
being proactive rather than merely reactive is a is recognized within a matrix of time. People may
significant feature of modern physiological rc- be described in similar terms as beings in the
search (Walker & Sandman, 1979, 1982). world who are patterned frequencies in time.

David Aldridge Collected music therapy papers 30


A phenomenological approach presses the sci- music). Music is the ideal medium to discover
entist to understand phenomena as dircct cxpcri- how people are composed and how they come
ences before being translated into thoughts and into the world as whole beings both to create and
feelings. The practice of creative music therapy sustain identity. Not only can such personal ex-
adopts such a position. A person is invited to pression be recorded for analysis, it can be heard
improvise music creatively with a therapist. It and experienced directly as a whole.
may be inferred from this playing that one is
hearing a person directly in the world as a dircct
expression of those patterned frequencies in a References
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David Aldridge Collected music therapy papers 31


MUSIC AND THE SELF
Morgan, 0. S., & Tilluckdharry, R. (1982). Presentation of Sandman, C. A. (1984). Afferent influences on the cortical
singing function in severe aphasia. West Indian Medical evoked response. In M. Coles, J. R. Jennings, & J. A.
Journal, 31, 159-161. Stern (Eds.), Psycliological perspectives (Festschrift for
Morley, J. B. (l98 1). Music and neurology. Clinical am1 Ex- Beatrice and John Lacey). Stroudberg, PA: Hutchinson &
' periine~ztulNeurology, 17, 15-25. Ross.
Morrongiello, B., Trehub, S. E., Thorpe, L. A., & Podilupo, Steedman, M. J . (1977). The perception of musical rhythm
S. (1985). Children's perception of melodies: The role o l ;ind metre. Perception, 6, 555-569.
contour, frequency and rate of presentation. Journal of' Wiigncr, M . T., & Haniton, R. (1981). Hemispheric asym-
Experimental Child P.sycliolof~,40, 279-292. m e t r i c ~ in faculty and student musicians and non-
Nordoff, P., & Robbins, C. (1977). Crcutivc music tlu-nipy. musicians duriny melody recognition tasks. Brain and
Individualized treatment / o r tlie luinciicapped cliilcl. New , 379-388.
L t ~ t ~ g u a g e13,
York: John Day. Walker, A. (1979). Music and the unconscious. British Medi-
Povel, D. J. (1984). A theoretical framework Ibr rhythni pcr- cul Jmirnul, 2 , 164 1-1643.
ception. Psycholofical Rfsecircli, 45, 315-337. Walker, B. B., & Sandman, C. A. (1979). Human visual
Safranek, M. G., Koshland, G . F., & Raymond, G . (1982). evoked responses are related to heart rate. Journal of
Effect of auditory rhythm on muscle activity. l'l~y,\icul Comparative rind I'liysiolofficul Psychology, 93, 7 17-729.
TIti-rapy, 62, 16 1- 168. Walker, B. B., & Sandman, C. A. (1982). Visual evoked po-
tcntiiils change ;is heart rate and carotid pressure change.
Psyrliopliysiolo~y,19, 520-526.

David Aldridge Collected music therapy papers 32


Journal of the Royal Society of Medicine Volume 82 December 1989 743

Music, communication and medicine: discussion paper

D Aldridge RID Medical Faculty, Uniuersitat Witten Herdecke, Beckweg 4 D-5804 Herdeke (Ruhr), FRG

Keywords: music therapy; physiology; communication; child development; rhythm entrainment

'The body of the speaker dances i n time with his speech. Physiology and communication
Further, the body of the listener dances i n rhythm with that At the molecular level the immune system and nervous
of the speaker!' system communicate with each other. Psychological
(Condon and Ogston, p 338) stress and social stress influences the immune system,
sometimes adversely. The relationship between neuro-
In our work as a department of music therapy within endocrine and immune systems is one of mutual
the faculty of medicine in a West German teaching comm~nication~,~. Our bodies are engaged in a con-
hospital we have begun to explore links between the tinuing communicative process out of the range of
playing of improvized music as therapy and the conscious awareness. These communications are vital
practice of medicine. Music therapists work with for life. We can, as Rossi5 says
physicians within the hospital as complementary
practitioners. We have attempted to develop a '. . . conceptualize a fairly complete channel of information
common language by which patients are described. transduction between mind a s it is experientially encoded
in the limbic-hypothalamic system filter, and the autonomic
This language calls upon the art of medicine as much
endocrine, immune, and neuropeptide systems that transmit
as it does upon the science of medicine. Our contention their "messenger" molecules to the organs and tissues and
is that human beings have a personal identity which to the cellular, genetic, and ultimately molecular levels'.
is musical1. When we search for a metaphor which (P 52)
informs the way we describe ourselves then we can
In this approach mind and body are united within a
say that we are symphonic, rather than mechanic,
rhythmic context of communication which enables
beings.
healing to take place. At the core of this work is the
The main argument of this paper is that musical
idea that the suprachiasmatic nucleus of the hypo-
components are the fundamentals of communication;
thalamus is a regulator of the ultradian (within a
and that rhythm, in particular, is the musical
day) rhythms7 responsible for autonomic system
aspect of communication fundamental to the way
regulation and cerebral dominance5.When the normal
in which we relate to ourselves and to others.
periodicity of these rhythms is disturbed by stress then
Communication in this sense is not solely restricted
psychosomatic reactions may occur. The restoration of
to the transmission of information, but is also
an integrated rhythmic hypothalamic response should
concerned with the establishment and management
be an important factor in the process of healing. It
of relationships2.
is feasible then that music therapy is an ideal medium
If this argument is true then music is a powerful
for promoting such integration and regulation through
and subtle medium of communication which is
rhythm.
isomorphic with the process of living3y4 and music
therapy can be a powerful therapeutic medium for
Synchrony, rhythm and communication
promoting communication.
The focus for understanding communication is how 'Curative chronobiotics may be visualized for disease such
the human being can maintain a coherent identity in as certain emotional disorders or rheumatoid arthritis - if,
a personal and interpersonal milieu. This continually and only if, rhythm alternation can be recognized to be
maintained coherence is a creative act. None of us as etiologically significant" (p 487).
human beings are islands isolated in the universe. We For communicationto occur there has to be an element
are organisms which act and interact with the of predictability by which events are structured. This
environment. We experience the world and attempt communication occurs within a matrix of time and is
to influence it. Communication is the process by which manifested as particular rhythms. These may be the
we interact with our environment which includes the circadian rhythms (literally about a day) of temper-
interpersonal milieux of our friends, colleagues and ature and sleep in humans, the shorter ultradian
lovers. It is the medium by which we negotiate our (within a day) rhythms of autonomic system regulation
self image in those relationships and integrate and metabolic processes, or the shorter periodicities
ourselves with others. of respiration, peristalsis and heart rate7-9.These are
Dialogue and exchange of information, the regulation the regulatory mechanisms by which self synchrony
of interpersonal distance and personal boundary, is maintained as a process of internal communication.
the mutual expression of human emotion and the The work of C ~ n d o n ~ O clearly
- ~ ~ shows the inte-
sharing of ideas are based upon communication. gration in terms of verbal behaviour, including
These are located within a matrix of time which is silence, and bodily gestures. There is a self syn- o141~076818gl
not static. Sequence, order and phrasing, the funda- c o n o u s organization to h and movement which 120743-041~02~0010
mentals of musical form are vital elements in is essentially rhythmic. Rhythm provides the means Q1989
maintaining coherence whether in physiological by which behaviour is organized. The Royal
systems, personal development or interpersonal However, Condon12goes on to write that as human Society of
relationships. beings we also communicate with other people. This Medicine
David Aldridge Collected music therapy papers 33
744 Journal of the Royal Society of Medicine Volume 82 December 1989

he calls 'interactional' synchrony. We are active alone, or words themselves seem inadequate. The
participants in communication. When we listen we communication of passions, love, ecstasy or anger are
move synchronously with the articulatory structure rarely dependent solely on words. At such times
of the speaker's speech. As the speaker moves with vocalizations and gestures are far more subtle and
his own speech, then so does the listener too. What 'meaningful' than words.
is 'sent' and 'received' are inseparable in the ordered
context of communication. This gives additional Child development and rhythmic interaction
support to the idea, to which some music therapists The development of language and socialization
refer, when they say that therapist and patient are in the infant depends upon learning the rhythmic
'united in the music'. In Condon's words12 structure of synchronization13.From birth the infant
'But what flows through them is a similar order; so that what has the genetic basis of an individually entrained
is sent and what is received are understood and shared by physiology, ie a self synchronicity. The infant has its
both speaker and listener. What all aspects of this process own time as 'kairos'. Yet, the process of socialization,
have in common is the propagation and reception of order. and the use of language depends upon entraining
There is no "between" i n the continuum of order.' (p 56). those rhythms with those of another, ie an inter-
As rhythms are entrained, or synchronized, within actional synchrony as 'chronos'. This interactional
the individual, then the listener will entrain with the synchrony could reflect those neural timing mech-
emergent rhythmic structure of the speaker, singer anisms which form the ground of communication
or player. By watching the movement of the listeners where interactional cycles of attention and affect
body as well as by observing the way in which the are entrained with homeostatic mechanisms in the
listener plays it is possible to glean some ideas about nervous system16.
their perceptual involvement. Lester et aZ.17 investigated the synchronization of
neonatal movement and the speech sounds of the adult
Phrasing talking to the baby. They argued that the ability of
A central feature of both musical and biological form the infant to attend to social stimuli was related to
is phrasing. When we speak in dialogues then we the infant's capacity for self regulation. Cycles of
must know when a phrase is ending, and how to begin rhythmic interaction between infants and mothers,
another. This occurs in speech by accented differences they argued, reflected an increasing ability by the infant
in a rhythmic context. When we listen we give a to organize cognitive and affective experience within
continuous feedback by small motions and gestures the rhythmic structure provided by the parent.
of our heads and bodies, and vocalizations. When a However, this was not a one-sided phenomenon.
phrase is coming to an end there is an increase or Infants produce forms of expression and gesture that are
change in such activity13. not imitations of maternal behaviour18J9.Both baby
Interactional synchrony between people, and the co- and mother learn each others rhythmic structure and
ordination of phrasing in communication, cannot be modify their own behaviour to fit that structure.
explained as reaction or as a reflex response to sound Arousal, affect and attention are learned within the
or movement. Synchronization is achieved by a shared rhythm of a relationship.
interaction in a rhythmic context known to both This is the method employed in music therapy. The
participants. The basis of such mutual knowledge is rhythmic structure of the patient is discovered by
both physiological, in that we share common the therapist, and the patient is then met within that
physiologies, and cultural14. The forces which bind rhythmic structure.
us together, which are the essence of our mutuality, Stern et al.20studied the non-verbal behaviour of
are musical. mothers and infants. They found two parallel modes
of communication.
Non-verbal communication and relationship One form of communication was that of CO-action.
As the preceding paragraphs suggest, communication In this form both mother and infant vocalize together.
occurs in a context of relationship. Peggy Perm2writes These authors suggest that coactional vocalizing is
that 'All emotions are an indication of how someone else an early pattern of behaviour which is structurally
is to behave' (p 17). All too often when we consider and functionally similar to mutual gaze, posture
communication in the context of therapy we concentrate sharing and rhythm sharing. It occurs during the
on the semantic bases of communication when it is the highest levels of arousal and is indicative of emotional
relational aspects of the interaction which are primary. tone. In adults CO-active vocalizing occurs in situations
Language and non-verbal behaviours are powerful of interpersonal arousal such as intense anger,
organizers of personal and social actions2J4. In sadness, joy or lovemaking.
studying communication the role of verbal behaviour The contrasting form is that of alternation. This mode
is often over-emphasized, and the role of non-verbal of communicationis that found in conversationwhere
behaviour neglected. This places a n emphasis on the speaker and listener alternately exchange roles. It is
'what' of communication (ie the content of communi- a dialogic pattern and valuable for the exchange of
cation)rather than the 'how' of communication (ie the symbolic information. This alternative mode is
regulation of that communication). The non-verbal valuable for the acquisition of language. It allows
aspects of communication indicate how the content information to be sent by one person while being
is to be received. Watzlawick et al. l5 call this process processed by the other. However, it is a separate
'metacommunication'; a communication about a pattern to that of CO-action.
communication. For example; the comment 'Oh, very CO-actionemphasizes the event of communication it-
interesting' can have quite a different meaning self, rather than the content of the communication.
according to the tone of voice and gesture used to Simultaneous vocalization promotes mutual experi-
David
deliverAldridge
it. Collected music therapy
ence andpapers
may be essential to the process of bonding and34
Sometimes information which is too powerful or feeling of relatedness. These two structurally different
--------- L _ l _ _ .  ¥ _ __-..__-L L - ---__---:--^.-.3 L J- c---rt ..-rt --.....A.+ .Â¥: +Lrt-1rt.rl-nrv .c Â¥;.......rt. :---id -.. --in
Journal of the Royal Society of Medicine Volume 82 December 1989 745

Communication and pathology This work resulted in Condon postulating a con-


If musical elements are essential to communication, tinuum of degrees of delayed response to sound with
then the improvized musical playing of people may autistic-like behaviour at the severe end and learning
make manifest both underlying pathology and possi- disabilities a t the milder end. (While not evident as
bilities for growth and change. a motor abnormality during conversation, these
Condon and Ogston1Âcompared normal and path- children had difTiculty with reading and mathematics).
ological behaviour between patients and therapists The observed children responded to an immediate
using the medium of film. Human interaction was actual sound but also appeared to respond again to
filmed. The films were then viewed repeatedly one that same sound with a delay 'by as much as % to a
frame a t a time, and analysed. Each frame was full second'll (p 47).
numbered and sequences of frames analysed according He gives the example of a 2% year old child
to speech and vocalization correlated with body throwing a block on a table. The block lands on the
movements. The authors call this the study of table and the child picks up another such block. The
'linguistics-kinesics'1Â (p 38). childs' hands suddenly move in a jerky and seemingly
When the same authors studied a chronic schizo- bizarre manner. Microanalysis of the film revealed
phrenic patient they found that there was a noticeable that the child's body moved synchronously with the
lack of head movements and rigidity of posture in the sound of the brick hitting the table. At a later time,
patient compared to the relatively free head movement 16 film frames, the jerky hand movements occurred.
of normal speakers. The expressive qualities of These hand movements were isomorphic with the
speech and movement were severely restricted. A self- sound and movements which occurred 16 film frames
dysynchrony also appeared in the schizophrenic earlier. (There were 24 film frames per second). By
patient where body movements appeared to be delaying the film sound to coincide with the move-
laterally separate. ment the child was seen to move in precise synchrony.
In the micro-analysis of films of depressed patients It was possible to see and hear the occurrence of a
by Condon1Â prosodic features of pitch, stress, sound on film and predict the occurrence of a bodily
phrasing and timbre were found which seemed movement 16 frames later without any sound
indicative of underlying pathology; occurring at that time.
'A marked laxity of articulatory movements characterizedthe
In children with a delayed response to sound
speech of these patients. With its sparing use of pitch and their behaviour appeared to be dominated by that
accent, their voice had a dead listless quality: changes of pitch delay. Furthermore, these children often lacked
covered a narrow tonal range and were predominantly step- a co-ordination between hearing a sound and
wise rather than gliding; hovering tones appeared at the end visually locating that sound. These children were
of sentences, . . .intonations tended to occur in the same stereo- literally out of time with the sensory structure of their
typed patterns; and emphatic accents were either rare or world.
absent entirely. Their speech gave an impression of being slow The entrainment of vision and sound gives an
and halting because of the frequent appearance of hesitation important spatial location in the world. To com-
pauses interrupting the flow of their phrases' (p 344). municate we need to be entrained both within
It is evident from this description that these are also ourselves and with our environment. A delay in sound
musical qualities, and if the improvized playing of a processing can lead to estrangement from the world
depressed patient was heard then a music therapist and personal incoherence.
would be making similar comments.
Fraser et aLZ1showed similar discriminating lin- Discussion
guistic profiles of schizophrenic and manic patients. The basic elements of human communication are
There was a continuum of linguistic degeneration musical. Physiological, psychological and social activity
across the psychotic spectrum. In an experimental occur in a context of time which is dynamic and the
control group 'normal' subjects produced fluent, structure of which is musical. At a fundamental level
complex and error free utterances. Schizophrenic human activity is organized as a hierarchy of
patients produced dysfluent, simple and error ridden rhythmic entrainment; within the individual as self-
speech. synchrony, and within relationships as interactional
Interestingly, when these patients improved clinically synchrony.
sentences became more tightly constructed and pitch When the breakdown of this synchronous be-
widened in range and became more melodically haviour occurs then pathology is evident. The
varied. Again clinical improvement can be heard in restriction of musical aspects of communication,pitch,
the musical (prosodic or suprasegmental) aspects of stress, articulation, timbre and fluency, appear to
speech style. be indicative of psychopathology. An improvement
Condonl1continued to develop this diagnostic work in these qualities appears to be evident in a
further studying the integration of body motion and return to health and the maintenance of a coherent
speech across many dimensions, particularly in the identity.
field of autistic-like behaviour. His frame by frame It is possible to hypothesize that improvized music
filmed micro-analysis of patients with various syn- therapyzz is a powerful tool for promoting
dromes like petit mal, Huntington's chorea, autism, communication in terms of personal and interpersonal
stuttering, parkinsonism and aphasia, led him to integration. Alternative creative dialogues may be
believe that there may be some relationship between encouraged within the person such that they are not
their problems and an underlying dysfunction in sound estranged within themselves, or estranged from
processing. Many of the behavioural mannerisms he others. Furthermore, clinicians, no matter in which
observed in children appeared to be related to a discipline they have their origins, may be advised to
multiple response to sound; there was both a n attend to the musical components of communication.
immediate response and a delayed response to a sound In this way the arts, as well as science, may inform
David or
event, Aldridge
'dyssynchrony'. Collected music therapy papers
the practice of medicine. 35
746 Journal of the Royal Society of Medicine Volume 82 December 1989

References relationship of verbal and non-verbal communication.


1 Aldridge D. A phenomenonlogical comparison of the The Hague: Mouton, 1980:49-65
organization of music and the self. Arts in Psychotherapy Kempton W. The rhythmic basis of interactional
1989;16:(in press) microsynchrony. In: Key MR. ed. The relationship of
2 Penn P. Coalitions and binding interactions in families verbal and non-verbal communication. The Hague:
with chronic illness. Fam Systems Med 1983;1:16-26 Mouton, 1980:68-75
3 Aldridge D. The development of a research strategy Key MR. The relationship of verbal and non-verbal
for music therapists in a hospital setting. Arts in communication. The Hague: Mouton, 1980
Psychotherapy 1989;16:(in press) Watzlawick P, Beavin JH, Jackson DD. Pragmatics of
4 Aldridge D. Physiological change, communication and human communication. New York: WW Norton, 1967
the playing of improvised music. Arts in Psychotherapy Linden W. A microanalysis of autonomic activity during
1989;16:(in press) human speech. Psychosom Med 1987;49:562-78
5 Rossi EL. From mind to molecule: A state-dependent Lester BM, Hoffman J , Brazelton TB. The rhythmic
memory, learning and behavior theory of mind-body structure of mother-infant interaction i n term and pro-
healing. Advances 1987;4:46-60 term infants. Child Dev 1985;56:15-27
6 Tee DE. Another look a t the interaction of psyche and Murray L, Trevarthen C. The infant's role in
soma. Complementary Med Res 1987;2:1-2 mother-infant communications. J Child Long 1986;
7 Moore-Ede MC, Czeisler CA, Richardson GS.Circadian 1315-29
timekeeping in health and disease. N Engl J Med Trevarthen C. Facial expressions of emotion in mother-
1983;309:469-79 infant interaction. Human Neurobiol 1985;4:4-21
8 Reinberg A, Halberg F. Circadian chronopharmacology. S t e m DN, Jaffe J, Bebbe B, Bennett SL. Vocalizing in
Ann Rev Pharmacol1971;11:455-92 unison and in alternation: two modes of communication
9 Johnson C, Woodland-Hastings J. The elusive mechanism within the mother infant dyad. Ann NY Acad Sci
of the circadian clock. Am Sci 1986;74:29-36 1975;263:89-100
10 Condon WS, Ogston WD. Sound film analysis of normal Fraser WI, King K, Thomas P, Kendell RE. The
and pathological behavior patterns. J Nerv Ment Dis diagnosis of schizophrenia by language analysis. Br J
1966;14:338-47 Pyschiatry 1986;148:275-8
11 Condon W. Multiple response to sound in dysfunctional Nordoff P, Bobbins C. Creative music therapy. New York:
children. JAutism Childhood Schizophrenia1975;5:37-56 John Day, 1977
12 Condon W. The relation of interactional synchrony to
cognitive and emotional processes. In: Key MR, ed. The (Accepted 25 May 1989)

David Aldridge Collected music therapy papers 36


The Arts in Psychotherapy, Vol. 18, pp. 359-362. Pergamon Press plc, 1991. Printed in the U.S.A. 0197-4556191 $3.00 + .00

REFLECTIONS

CREATIVITY AND CONSCIOUSNESS:


MUSIC THERAPY IN INTENSIVE CARE

DAVID ALDRIDGE, PhD*

' . . however great the organic damage . . . there sidered. It raises questions about the location of the
remains the undiminished possibility of reintegration self in patients who are comatose, about the nature of
by art, by communion, by blocking the human spirit; communication with patients who are unconscious,
and this can be presented in what at first seems at first and challenges medicine to realize the human body as
a hopeless state of neurological devastation."
an instrument of knowledge.
(Sacks, 1986, p. 37)
Some aspects of modem medicine have become
increasingly technological. Such is the case of inten-
The neurologist Oliver Sacks reminds us of the
sive care treatment. Even in what may appear to be
necessary balance we must bring to our work with
patients in the field of medicine. All too often we are hopeless cases, it can save lives (Hannich, 1988)
through the application of this modem technology.
concerned with testing the patient for deficits, for
measuring and for assessing problem-solving capaci- However, albeit in the context of undoubted success,
intensive care treatment has fallen into disrepute.
ties. As a balance he urges us to consider the narrative
Patients are seen to suffer from a wide range of
and symbolic organization of the patients, so that we
consider their possibilities and abilities. In this way problems resulting from insufficient communication,
sleep and sensory deprivation (Hannich, 1988; Ul-
what seems to be damaged, ill-organized, and chaotic
rich, 1984), and lack of empathy between patient and
becomes composed and fluent. This is the function of
the creative arts; through art and play we realize other medical staff. Many activities in an intensive care
selves elusive to measurement and fugitive to assess- situation appear to be between the unit staff and the
ment. Furthermore, there is a quality of time that is essential machines (i.e., subjects and objects). To a
certain extent, patients become a part of this object
apparent in arts activities that is "intentional7' and
involves the will of the patients where their spirits are world. Improvised music therapy can be a useful
adjunctive therapy in such situations both for the
set free. When we consider the situation of intensive
patient and the staff.
care, where patients are often damaged, disorganized,
intubated, machine-regulated, often unconscious, and
unable to communicate, then we must consider a way The Music Therapy Sessions
of introducing activities that will stimulate commun-
ion with those patients. At the suggestion of a hospital neurologist, a music
In this paper the ground of consciousness is con- therapist began working with patients in intensive

*David Aldridge is a research consultant to the medical faculty of Universit'at Witten Herdecke, Germany.
He thanks Dr. Wilhelm Rimpau for the initiation of this work, Dagmar Gustorff for her pioneering of these skills in difficult conditions,
and Professor H.J. Hannich for his providing the circumstances for the further exploration of this work.

359

David Aldridge Collected music therapy papers 37


360 DAVID ALDRIDGE

care (Gustorff, 1990). To investigate this approach movements, grabbing movements of the hand, and
further, the work was monitored in the intensive turning of the head, eyes opening to the regaining of
treatment unit of a large university clinic. Five consciousness. When the therapist first began to sing
patients, between the ages of 15 and 40 years, and there was a slowing down of the heart rate. Then the
with severe coma (a Glasgow Coma Scale score heart rate rose rapidly and sustained an elevated level
between 4 and 7) were treated. All the patients had until the end of the contact. This may have indicated
been involved in some sort of accident, had sustained an attempt at orientation and cognitive processing
brain damage, and most had undergone neurosurgery. within the communicational context (Nordoff & Rob-
The form of music therapy used here was based on bins, 1977; Sandman, 1984a, 1984b). Electroenceph-
the principle that we are organized as human beings alogram (EEG) measurement of brain activity showed
not in a mechanical way but in a musical form (i.e., a desynchronization from theta rhythm, to alpha
a harmonic complex of interacting rhythms and me- rhythm or beta rhythm in former synchronized areas.
lodic contours) (Aldridge, 1989a, 1989b; Nordoff & This effect, indicating arousal and perceptual activity,
Robbins, 1977). To maintain our coherence as beings fades out after the music therapy stops.
in the world we must creatively improvise our iden- If we consider that cells firing with a cardiac
tity. Rather than search for a master clock that rhythm have been recorded in the medullary area of
coordinates us chronobiologically, we argue that we the brain, and that there is a synchronous relationship
are better served by the non-mechanistic concept of between the contraction of the heart and the "ascend-
musical organization. Music therapy is the medium ing" wave of alpha rhythm (Sandman, 1986) of brain
by which a coherent organization is regained (i.e., activity, then it is possible to hypothesize that the
linking brain, body, and mind). In this perspective, rhythmic coordination of the cardiovascular system
the self is more than a corporeal being. As Sacks with cortical rhythmic firings is of primary impor-
(1986) wrote, "the power of music or narrative form tance for cognition. What we have is a weaving
is to organize" (p. 177). What music and narrative together of basic primitive human rhythms, which
structure organizes is the recognition of relationships produce an interference pattern that itself may be that
between elements, not in an intellectual way, but of cognition. It is proposed here that the rhythmic
direct and unmediated. With coma patients we see coordination of basic functions in the human body
signs of activity, albeit often machine supported, but (Jones, Kidd, & Wetzel, 1981; Kempton, 1980;
totally disorganized. The person exists, sometimes in Kidd, Boltz, & Jones, 1984; Lester, Hoffman, &
what is described as a vegetative state, but hardly Brazelton, 1985;Longuet-Higgins, 1982; Povel, 1984;
''lives. " Rozzano & Locsin, 1981; Safranek, Koshland, &
Each music therapy contact lasted between eight Raymond, 1982; Steedman, 1977) is a fundamental
and twelve minutes. The therapist improvised her healing activity.
wordless singing based on the tempo of the patient's
pulse and, more importantly, the patient's breathing The Ward Situation
pattern. She pitched her singing to a tuning fork. The Sleep disturbance is a major problem in intensive
character of the patient's breathing determined the care units and the effect of a disturbed waking1
nature of the singing. The singing was clearly phrased sleeping rhythm upon other metabolic cycles is criti-
so that when any reaction was seen the phrase could cal (Johnson & Woodland-Hastings, 1986; Moore-
be repeated. Ede, Czeisler, & Richardson, 1983; Reinberg &
Before the first session the music therapist met the Halberg, 1971). The rhythmic entrainment of cardio-
family to gain some idea of what the patient was like. vascular and somatic activities may be the key ground
On contacting the comatose patient, she said who she for recovery. This means that we must consider the
was, that she would sing for the patient in the tempo total "behavioral" (Engel, 1986) activity of the
of his or her pulse and the rhythm of breathing. The patient so that seemingly independent systems are
unit staff were asked to be quiet during this period and integrated. The context (i.e., Latin, con textere =
not to carry out any invasive procedures for ten weaving together) of this integration is rhythmical
minutes after the contact. involving the coordination of the major tidal rhythms
There was a range of reactions from a change in of the body and timing mechanisms within the hypo-
breathing (it became slower and deeper), fine motor thalamus in the brain.

David Aldridge Collected music therapy papers 38


MUSIC THERAPY IN INTENSIVE CARE 361

As an organizational problem, we must look to the cannot do. Perhaps the key lies in the fact that it is the
ways in which staff are employed in work shifts. It consciousness of the therapist that stimulates the
can occur that patients throughout 24 hours are consciousness of the patient, and this consciousness is
constantly in contact with nursing staff who are in not divorced from the living rhythmic reality of our
their own activity cycle, no matter what time of day or physiology.
night. For rhythmically disoriented patients, no won- A period of calm is also recognized as having
der that there are sleep problems when they must potential benefit for the patient. What some staff fail
respond to constant activity with caregivers who to realize is that communication is dependent on
themselves are physically unsynchronized with the rhythm, not on volume. We might argue that such
patient. Nursing staff, although synchronized with unconscious patients, struggling to orient themselves
management needs and hospital routine, may need to in time and space, are further confused by an atmo-
attend to the sleeplactivity rhythm of the patient. sphere of continuing loud, disorienting random noise,
In response to the music therapy, some ward staff and bright light. For patients seeking to orient them-
are astonished that patients can respond to quiet selves, the basic rhythmic context of their own
singing. This highlights a difficulty of noisy, busy, breathing may provide the focus for that orientation.
often brightly lit units. All communication is made This raises the problem of intentionality in human
above a high level of machine noise. Furthermore, behavior even when consciousness appears to be
commands to an "unconscious" patient are made by absent. Reflexes do not occur in a vacuum; they are
shouting formal injunctions (i.e., "Show me your conditional occurring in a context of other behavioral
tongue," "Tell me your name," "Open your eyes"). activity. If bodily systems are proactive, as well as
Few attempts are made at normal human communi- reactive, then purposive behavior and consciousness
cation with a patient who cannot speak or with whom may require the context of human communication to
staff can not have any psychological contact. It is as function. It is also vital that staff in such situations do
if these patients were isolated in a landscape of noise, not confuse "not acting" on the behalf of the patient
and deprived of human contact. with "not perceiving. "
A benefit of music therapy is that the staff are We can further speculate that the various body
made aware of the quality and intensity of the human rhythms have become disassociated in comatose states
contact. In the intensive care unit environment of and following major surgery. The question remains of
seemingly non-responding patients, dependent on how those behaviors can be integrated and where the
machines to maintain vital functions and anxiety seat of such integration is. It is quite clear that
provoking in terms of possible patient death, then it is integration is an organizational property of the whole
a human reaction to withdraw personal contact and organization in relationship with the environment and
interact with the machines. Although the machines not located in any cell or any one organ. The
themselves are of vital importance, they present data environment of the patient includes the vital compo-
that are independent one from another, and that are nent of human contact and there is reason to believe
often considered in isolation, whereas the integration that the essential ground of this contact too is rhyth-
of the systems being measured is the clue to recovery. mical.
This is further exacerbated by a scientific epistemol-
ogy that emphasizes the person only as a material
being and that equates mind with brain. Communication, Contact, and Consciousness
At yet another level, we must consider the fixed Improvised singing appears to offer a number of
chronological pulses of machines. If human activity is possible benefits for working in intensive care both in
based on pulse, the nature of those pulses is that they terms of human contact and promoting perceptual
are variable within a range of reactivity. Those pulses responses. Human contact as communication is a
are lively and accommodate other pulses to form creative art form. Although what we know from
interacting rhythms. This is not so with machines; machines is valuable, there are other important subtle
they are fixed in their range. Therefore, what is a forms of knowledge that are best gleaned through
variable in human activity (the tempo of varying personal contact with the patient. Mindell (1989) took
pulses) becomes a constant in these patients. The task the courageous step of attempting process-oriented
then is to introduce coordinated variety with the psychology with comatose patients, accompanying
intention to heal, something that as yet machines them on their great symbolic journey. The drama of

David Aldridge Collected music therapy papers 39


362 DAVID ALDRIDGE

our contact with such patients at a time of existential References


crisis points to a fundamental aesthetic of living Aldridge, D. (1989a). Music, communication and medicine.
systems creatively realized so that we, as artist Journal of the Royal Society of Medicine, 82, 743-745.
therapists, can go beyond the confines of a soulless Aldridge, D. (1989b). A phenomenological comparison of the
technology. This is not to deny that technology and its organization of music and the self. The Arts in Psychother-
apy, 16, 91-97.
benefits, simply to remind us of our human intention
Engel, B.T. (1986). An essay on the circulation as behavior. The
as it is realized in art, play, drama, music. Behavioral and Brain Sciences, 9 , 285-3 18.
What we may also need to consider in future is not Gustorff, D. (1990). Lieder ohne Worte. Musiktherapeutische
how to observe more, but how to question the quality Umschau, 11, 120-126.
of what we are observing and the premises on which Hannich, H.J. (1988). Uberlegen zum Handlungsprimat in der
Intensivmedizin. Medizin Mensch Gesellschaft, 13, 238-244.
this observation is based. In such situations of inten- Johnson, C., & Woodland-Hastings, J. (1986). The elusive mech-
sive monitoring and machine support, particularly in anism of the circadian clock. American Scientist, 74, 29-36.
the case of comatose patients, we may ask of our- Jones, M,, Kidd, G., & Wetzel, R. (1981). Evidence for rhythmic
selves, "Where is the self of the patient?" Needle- attention. Journal of Eqerirnental Psychology, 7 , 1059-1073.
man (1988) reminds us that the power of scientific Kempton, W. (1980). The rhythmic basis of interactional mi-
crosynchrony. In M. Key (Ed.), The relationship of verbal and
thought has been to organize our perceptions in such non-verbal communication (pp. 68-75). The Hague: Mouton.
a manner that we can survive in the world. Hence the Kidd, G., Boltz, M,,& Jones, M. (1984). Some effects of
value of scientific medicine and instrumentation. rhythmic content on melody recognition. American Journal of
However, he goes on to say that science has also Psychology, 97, 153-173.
Lester, B. M., Hoffman, J., & Brazelton, T. (1985). The rhyth-
neglected the human body as an instrument of knowl- mic structure of mother-infant interaction in term and proterm
edge and as a vehicle for sensations as direct as infants. Child Development, 56, 15-27.
ordinary sensory experience, but as subtle as con- Longuet-Higgins, H. (1982). The perception of musical rhythms.
sciousness. He writes ". . . it is not simply the Perception, 11, 115-128.
Mindell, A. (1989). Coma: Key to awakening. Boston: Shambala.
intellect which science underestimates, it is the hu-
Moore-Ede, M. C., Czeisler, C. A., & Richardson. G. S.
man body as an instrument of knowledge-the human (1983). Circadian timekeeping in health and disease. New
body as a vehicle for sensations as direct as ordinary England Journal of Medicine, 309, 469-479.
sensory experience, but far more subtle and requiring Needleman, J. (1988). A sense of the cosmos. New York: Arkana.
for their reception a specific degree of collected Nordoff, P., & Robbins, C. (1977). Creative music therapy. New
York: John Day.
attention and self-sincerity" (p. 169). Povel, D. (1984). A theoretical framework for rhythm percep-
The question still remains for us as clinicians and tion. Psychological Research, 45, 315-337.
scientists when faced with a patient in coma or a Reinberg, A., & Halberg, F. (1971). Circadian chronopharma-
persistent vegetative state, "Where is the person and cology. Annual Review of Pharmacology, 11, 455-492.
how can I reach him or her?" and then for ourselves Rozzano, G., & Locsin, R. (1981). The effect of music on the
pain of selected post operative patients. Journal of Advanced
as fellow human beings, "Where am I?" What part of Nursing, 6 , 19-25.
the therapist is contacting the unconscious patient? Sacks, 0. (1986). The man who mistook his wife for a hat. Lon-
Could it be that if the musical form of our communi- don: Pan.
cation touches our patients, as singing, we can also Safranek, M., Koshland, G. & Raymond, G. (1982). Effect of
auditory rhythm on music activity. Physical Therapy, 62,
attend to how we speak with the patients in their 161-168.
breathing patterns, and then attend to them with the Sandman, C. (1984a). Afferent influences on the cortical evoked
very form of our own bodies. response. In M. Coles, J. Jennings, & J. Stem (Eds.), Psy-
This ability to communicate with unconscious chophysiological perspectives: Festschrift for Beatrice and
John Lacey. Stroudberg, PA: Hutchinson & Ross.
patients raises further the ethical issues of decisions Sandman, C. (1984b). Augmentation of the auditory event related
about terminating life support when the brain and the to potentials of the brain during diastole. International Jour-
person are no longer seen as one and the same entity nal of Physiology, 2, 111-1 19.
(Mindell, 1989). When patients are not responding it Sandman, C. (1986). Circulation as consciousness. The Behav-
may be that we are not providing them with the ioural and Brain Sciences, 9, 303-304.
Steedman, M. (1977). The perception of musical rhythm and
human conditions in which, and with which, they can metre. Perception, 6 , 555-569.
respond. We as therapists are those conditions that are Ulrich, R. (1984). View through a window may influence recov-
the context for healing to take place. ery from surgery. Science, 224, 420421.

David Aldridge Collected music therapy papers 40


Journal of the Royal Society of Medicine Volume 83 June 1990 345

rhythm of breathing. The unit staff were asked to be


Where am I? quiet during this period and not to carry out any
Music therapy applied to coma patients invasive procedures for 10 min after the contact.
There were a range of reactions from a change in
breathing (it became slower and deeper), fine motor
Intensive care treatment is a highly technological movements, grabbing movements of the hand and
branch of medicine. Even in what may appear turning of the head, eyes opening to the regaining of
to be hopeless cases, i t can save lives1 through consciousness. When the therapist first began to sing
the application of this modern technology. How- there was a slowing down of the heart rate. Then the
ever, albeit in the context of undoubted success, heart rate rose rapidly and sustained an elevated level
intensive care treatment has fallen into disre- until the end of the contact. This may indicate a n
pute. Patients are seen to suffer from a wide attempt at orientation and cognitive processing within
range of problems resulting from insufficient com- the communicational c o n t e ~ t ~EEG* ~ . measurement
munication, sleep and sensory deprivation2s3 and showed a desynchronization from theta rhythm, to
lack of empathy between patient and medical staff. alpha rhythm or beta rhythm in former synchronized
Many activities in an intensive care situation appear areas. This effect, indicating arousal and perceptual
to be between the unit staff and the essential activity, faded out after the music therapy stopped.
machines, ie subjects and objects. To a certain extent Some of the ward staff were astonished that a patient
patients become a part of this object world. We propose could respond to such quiet singing. This highlights
that improvised music therapy can be a useful a difficulty of noisy units such as these. All communi-
adjunctive therapy in such situations both for the cation is made above a high level of machine noise.
patient and the staff. Furthermore commands to an 'unconscious'. patient
In these situations of intensive monitoring and are made by shouting formal injunctions, ie 'Show me
machine support, particularly in the case of comatose your tongue', 'Tell me your name', 'Open your eyes'.
patients, we may ask of ourselves 'Where is the self Few attempts are made a t normal human communi-
of the patient?'. Needleman4 reminds us that the cation with a patient who cannot speak or with whom
power of scientific thought has been to organize our staff can have any psychological contact. It is as if
perceptions i n such a manner that we can survive in these patients were isolated in a landscape of noise,
the world. Hence the value of scientific medicine and and deprived of human contact. !
instrumentation. However, he goes on to say that A benefit of the music therapy was that the staff
science has also neglected the human body as an were made aware of the quality and intensity of the
instrument of knowledge and a s a vehicle for sen- human contact. In the intensive care unit environ-
sations as direct as ordinary sensory experience, but ment of seemingly non-responding patients, depen-
a s subtle as consciousness. dent upon machines to maintain vital functions and
At the suggestion of a hospital neurologist a music anxiety provoking in terms of possible patient death,
therapist began working with coma patients. To then it is a human reaction to withdraw personal
investigate this approach further the work was contact and interact with the machines. This is
monitored i n an intensive treatment unit. Five further exacerbated by a scientific epistemology which
patients, between the ages of 15 and 40 years, and emphasizes the person only as a material being and
with severe coma (a Glasgow Coma Scale score which equates mind with brain.
between 4 and 7) were treated. All the patients had A period of calm was also recognized as having
been involved in some sort of accident, had sustained potential benefit for the patient. What some staff fail
brain damage and most had undergone neurosurgery. to realize is that communication is dependent upon
The form of music therapy used here is based on the rhythm, not upon volume. We might argue that such
principle that we are organized as human beings not unconscious patients, struggling to orient themselves
in a mechanical way but i n a musical form; ie a in time and space, are further confused by an
harmonic complex of interacting rhythms and melodic atmosphere of continuing loud and disorienting ran-
contour^^-^. To maintain our coherence as beings in dom noise. For patients seeking to orient themselves
the world then we must creatively improvise our then the basic rhythmic context of their own breathing
identity. Rather than search for a master clock which may provide the focus for that orientation. This raises
coordinates us chronobiologically, we argue that we the problem of intentionality in human behaviour,
are better served by the non-mechanistic concept of even when consciousness appears to be absent. It is
musical organization. Music therapy is the medium also vital that staff in such situations do not confuse
by which a coherent organization is regained, ie 'not acting' with 'not perceiving'.
linking brain, body and mind. In this perspective the We can speculate that the various body rhythms
self is more than a corporeal being. have become disassociated in such comatose states.
Each music therapy contact lasted between 8 and The question remains then of how those behaviours
12 min. The therapist improvised her wordless singing can be integrated and where is the seat of such
based upon the tempo of the patient's pulse, and more integration.
importantly, the patient's breathing pattern. She Improvised singing appears to offer a number of
pitched her singing to a tuning fork. The character of possible benefits for working with coma patients in
the patient's breathing determined the nature of the terms of human contact and promoting perceptual
singing. The singing was clearly phrased so that when responses. Human contact through singing, rather
any reaction was seen then the phrase could be repeated. than speaking, also suggests that the fundamentals o141~0768190,
Before the first session the music therapist had met of human communication are musical in form. In this Mo3542802.,,,,o
the family to gain some idea of what the patient was way we have the a r t of medicine within the science a lgoo
like a s a person. On contacting the comatose patient of medicine. Perhaps the skills of human communi- ~h~ ~~~~l
she would say who she was, that she would sing for cation may become part of medical and nursing Society of
David
the Aldridge
patient Collected
in the tempo of his or her pulse music therapy
and the papers
education5, 41
particularly in the context of intensive Medicine
346 Journal of the Royal Society of Medicine Volume 83 June 1990

care. Although what we know from machines is References


valuable, there are other important subtle forms of 1 Hannich H. Uberlegen m m Handlungsprimat in der
knowledge that are best gleaned through personal Intensivmedizin. Medizin Mensch Gesellschaft
contact with the patient. 1988;13:238-44
The question still remains for us as clinicians and 2 Wilson L. Intensive care delirium. Arch Intern fed
scientists when faced with a patient in coma, or a 1972;130:225-6
3 Ulrich R. View through a window may influence
persistent vegetative state, 'Where is the person and recovery from surgery. Science 1984;224:420-1
how can I reach her?, and then for ourselves as fellow 4 Needleman J. A sense of the cosmos. New York:Arkana,
human beings, 'Where am I?' This raises further the 1988
ethical issues of decisions about terminating life 5 Aldridge D. A phenomenological comparison of the
support when the brain and the person are no longer organization of music and the self. Arts in Psychotherapy
seen as one and the same entitylO. 1989;16:91-7
6 Aldridge D. Music, communication and medicine. J R
Soc Med 1989;82:743-6
D Aldridge 7 NordoffP, Robbins C. Creative music therapy. New York,
Medical Faculty, John Day, 1977
Universitat Witten Herdecke 8 Sandman C . Afferent influences on the cortical evoked
Beckwig 4,D5804 Herdecke, FRG response. In: Coles M, Jennings JR,Stern JA eds.
D Gustorff Psychological perspectives (festscrift for Beatrice and
John Lacey). Stroudberg, PA: Hutchinson and Ross,
Znstitut fur Musiktherapie, Medical Faculty,
1984
Universitat Witten Herdecke 9 Sandman C. Augmentation of the auditory event related
H J Hannich to potentials of the brain during diastole. Znt J
Wilhelms-Universitat Klinic fur Aniisthesiologie Physiology 1984;2:111-19
und operatiu Intensivmedizin 10 Mindell A. Coma: key to awakening. Boston: Shambala,
Albert-Schweitzer-Strasse 33, D4400 Miinster, FRG 1989

regarding HIV infection, but also of general medicine


AIDS afterthought in preparation for Finals. Fortunately, a gynae-
cologist friend of my parents had trained in Sydney
and introduced me to a consultant immunologist
Barts students are no different from most final year there, Professor Ronal Penny. Thus I came to
medics in the need to choose a destination for the spend my elective a t St Vincent's Hospital, Sydney.
elective period. This need occasionally encompasses I was extremely fortunate in being funded by
a desire to journey to a warm and exotic part of the the Guildchrist Foundation, the Clothworkers Trust
world yet a t the same time is concerned with gaining and my Medical College, all in the City of London.
some medical experience. It is surprisingly difficult It was interesting that none of the London-based
to combine these two intentions especially since hot AIDS organizations were able to provide any assis-
climates are often associated with many outdoor tance despite my protocol covering the very serious
temptations which can divert thought away from negative social aspect of neuropsychiatric compli-
study and learning. cations of HIV infection.
My elective months were spent in Sydney, The public image of the AIDS victim has been the
Australia, a choice governed by my previous special infected homosexual or drug addict. Sydney, with its
studies in HIV and AIDS. This interest began in 1985 large population of both these sources of patients, also
when I joined St Mary's hospital for one year to study has people from every walk of life professing beliefs
'Infection and Immunity'. From that time, the subject and carrying out behaviour that, as in all cosmo-
of AIDS and the management of the immuno- politan society, has no norm. AIDS is making
compromised patient began to appear more frequently its grim inroad, indifferent to stereotyping. During
in medical journals. The neuropsychiatric compli- my time in Sydney, I saw many aspects of inpatient,
cations of HIV infection were of particular interest outpatient, community and laboratory care of HIV
since they demonstrated links between the immune infection. It is a sad game of numbers that the
system, opportunistic infection and psychological Australian population is not much more than a
symptoms in patients who practised diverse lifestyles. quarter that of the UK, but contains as many recorded
The extent to which the AIDS epidemic will domi- cases of AIDS. The field of neuropsychiatric compli-
nate current medical practice in the UK is still cations was too vast for deep investigation in
unclear. the limited time of the elective period. My work
My concern was to use my particular academic covered a broad overview of the illness and gave me
knowledge to support the clinical experience obtained a deep understanding of compassion. 0141-07681901
on elective. However, I had not had any direct 'AIDS patients? Did you wear a mask. I hope 060M6~021~02
personal involvement in the management of HIV you wore rubber gloves!' This was the reaction Q lggo
infection and for that reason alone was keen of several of my fellow students on my return l-he~~~~l
to spend some time attached to a unit where to London. I must say that, to an extent, these Society of
Davidwas
there Aldridge Collected
a possibility of some teaching, music therapy
not only papers
intimations of fear and caution echoed my own 42 Medicine
movements, grasping movements of the This raises the problem of intention in
Music Therapy and human behaviour even when con-
hand, turning of the head and eye opcn-
Intensive Care ing. When the therapist first begins to sciousness appears to be absent. It is
sing heart rate slows. Then it rises also vital that staff do not confuse "not
Keywords: MUSIC, COMA, INTENSIVE rapidly and sustains an elevated level responding" with "not receiving".
CARE until the end of the contact. This may We can further speculate that the
indicate an attempt at orientation and various body rhythms become dis-
cognitive processing.6" The EEG shows associated in comatose states and fol-
Patients in intensive care often suffer a desynchronization from theta rhythm, lowing major surgery. The question re-
through insufficient communication, to alpha rhythm or beta rhythm in for- mains then of how rhythms can be
inadequate sleep, sensory deprivation"2 mer synchronized areas. This effect, in- integrated and where is the seat of such
and lack of empathy between patient dicating arousal and perceptual activity, integration. It is very likely that it is a
and medical staff. Many activities in in- fades out after the music therapy stops. property of the whole organism. The
tensive care appear to be simply be- Neurones linked to cardiac rhythm environment of the patient includes the
tween unit staff and objects, and to a have been identified in the medulla and vital component of human contact and
certain extent patients become a part of there is a synchronous relationship be- there is reason to believe that the essen-
this object world. We propose that im- twccn the contraction of the heart and tial basis of this contact too is rhythmi-
provised music therapy can prove valu- the 'ascending' wave of the EEG alpha Improvised singing appears to offer
able in this context both for the patient rhythm.' It is possible that the rhythmic a number of possible benefits for inten-
a i d the staff. co-ordination of the cardiovascular sys- sive care both in terms of human contact
At the suggestion of a hospital tem with cortical rhythmic firing is of and promoting perceptual responses.
neurologist a music therapist began primary importance for cognition. Better responses to singing, rather than
working with patients in intensive care. Furthermore, sleep disturbance is a speaking, suggests that the fundamen-
Five patients, between the ages of 15 major problem in intensive care units tals of human communication are musi-
and 40 years, and with severe coma (a and the effect of a disturbed waking1 cal in form. In this way we have the art of
Glasgow Coma Scale score between 4 sleeping rhythm upon other metabolic m e d i c i n e w i t h i n t h e science of
and 7*) were treated. All had been in- cycles may be critical. The rhythmic en- medicine.
volved in some sort of trauma and had trainment of cardiovascular and somatic
sustained brain damage, and four had activities may be a key clement in recov-
undergone neurosur@ry. Music ther- ery. This means that we must consider
apy is based on the principle that we are the total 'behavio~ral'~ activity of the
organized as human beings not in a patient including rhythmical inte-
mechanical, chronobiological way but in gration of independent systems with
a musical fashion i.e. a harmonic com- major tidal rhythms of the body.
plex of interacting rhythms and melodic A patient's response to quiet singing 1. Wilson L. Intrnsivr ciiri* ik-lirium. A r h w tifhitfrwl h<rili-
contour^."^"' To maintain our coherence highlights a difficulty of noisy, busy, c h r 1972; 130: 225-h.
2. Ulrich R. View 111rtiui;h<i wiiulunv in.iy i n f l ~ n ~ i irfoivery
i~t~
as beings it seems we must creatively often brightly lit units where communi- from surgrry. Srii-iirr 1QM.224: 420-1.
maintain our identity. Music therapy is cation is hindered by continuous back- 3. Aldndge D. A plienon~.'ii~~Iugit'al annparistin of the orpni?.-
ationof music.ind tin-self An'. in Piyhllit'riily I'W*; ll>.'ll-
the medium by which coherent organiz- ground noise. Shouted commands to an 7.
ation is regained, linking brain, body unconscious patient include formal in-
and mind. In this perspective the self is junctions, i.e. "Show me your tongue",
more than simply a corporeal being. "Tell me your name", "Open your
Each music therapy contact lasts be- eyes". There may be few attempts made
tween eight and twelve minutes. The at normal h u m a n communication
therapist~mprovisesher wordless sing- where the patient cannot speak or
ing based upon the tempo of the where there is restricted physiological
patient's pulse, and more importantly, access. It is as if he were isolated in a
the patient's breathing pattern, pitching landscape of noise, and deprived of hu-
her singing to a tuning fork. The charac- man contact.
ter of the patient's breathing determines One benefit of music therapy is t o
the nature of the singing which is clearly remind the staff of the imnortance
' of the
quality and intensity of human contact. !+c also Yingling CD, liosobuchi V, llarrington M (1990) I'.KX
phrased so that when any reaction is asa prcilirtor of rortm'ry from coma. laurel 336: 873and Siwtr
seen the phrase can be repeated. Whilst life support and monitoring de- R (1990) Effectsof auditory stimuli on comatose pitients wilt
Before the first session the music vices are essential they encourage a head injury. Heart 1111d l.un{ I t : 37.3-H.-Kilitur

therapist meets the family to gain some mechanistic approach which sees the
idea of what the patient is like as a patient simply as a biological complex.
person. O n meeting the comatose A period of calm may also benefit the
patient she introduces herself and tells patient. What some staff may fail to
him she will sing in the tempo of his or recognize is that communication de-
her pulse and rhythm of breathing. The pends on rhythm, not simply upon vol-
Unit staff are asked to be quiet during u m e . Such unconscious patients,
this period and to avoid invasive pro- struggling to orient themselves in time
cedures for ten minutes after the con- and space, are further confused by an
tact. There is a range of reactions environment of continuing loud, disori-
including a change in breathing (it be- entating random noise and bright light.
comes slower and deeper), fine motor For these patients the basic rhythmic
context of their own breathing may pro-
"Normal score 15, worst score 3 vide the required focus for orientation.

INTENSIVE & CRITICAL CARE DIGEST Vol. 10 No. 1 MARCH 1991

David Aldridge Collected music therapy papers 43


Journal of the Royal Society of Medicine Volume 86 February 1993

Music and Alzheimer's disease -assessment


and therapy: discussion paper

D Aldridge P ~ D Medizinische Fakultat, Universitat Witten Herdecke,


Beckweg 4, D-5804Herdecke BRD, Germany

Keywords: dementia; Alzheimer's disease; music psychology; music therapy; mental state examination

Dementia is an important source of chronic disability Ravel, the composer, began to complain of increased
leading to both spiralling health care expenditure fatigue and lassitude. Following a traffic accident his
among the elderly and a progressive disturbance of condition deteriorated progressively. He lost the ability
life quality for the patient and his or her family. Withto remember names, to speak spontaneously and to
write. Although he could understand speech he was no
anticipated increases in the population of the elderly in
Europe, then it is timely to find treatment initiatives longer capable of the coordination required to lead a
in the Western world which will ameliorate the impact major orchestra. While his mind, he reports, was full of
of this problem. Music therapy while not offering a musical ideas, he could not set them down. Eventually
cure for such a disease may be in a position to offer his intellectual functions deteriorated until he could
amelioration of the impact of the disease and provide no longer recognize his own music. Even in a composer
a valuable adjunct to diagnosis. of his standing, with what we may guess was a
progressive dementing illness, his active music-making
The diagnosis of Alzheimer's disease is prone to error
and authors differ as to the difficulty of making a capabilities deteriorated, albeit after speech failed.
precise diagnosis. In the early stages of the disease the However, the responsiveness of patients with
symptoms are difficult to distinguish from those of Alzheimer's disease to music is a remarkable pheno-
normal aging, a process which itself is poorly under- menon. While language deterioration is a feature of
stood. A second source of error in diagnosing cognitive deficit, musical abilities appear to be
Alzheimer's disease is that it is masked by other preserved. This may be because the fundamentals of
conditions. Principle among these conditions is that language itself are musical, and are prior to semantic
of depression which itself can cause cognitive and and lexical functions in language development.
behavioural disorders. Although language processing may be dominant in
Clearly Alzheimer's disease causes distress for the one hemisphere of the brain, music production
patient. The loss of memory and the accompanying loss involves an understanding of the interaction of both
of language, before the onset of motor impairment, cerebral hemispheres. In attempting to understand
means that the daily lives of patients are disturbed. the perception of music there have been a number
Communication, the fabric of social contact, is inter- of investigations into the hemispheric strategies
rupted and disordered. The threat of progressive involved. Much of the literature considering musical
deterioration and behavioural disturbance has ramifi- perception concentrates on the significance of hemi-
cations not only for the patients themselves, but also spheric dominance. Gates and Bradshaw2 conclude
their families who must take some of the social that cerebral hemispheres are concerned with music
responsibility for the care of the patient, and the perception and that no laterality differences are
emotional burden of seeing a loved one becoming apparent. Other authors suggest that two processing
confused and isolated. functions develop with training where left and right
A brief cognitive test, the Mini-Mental State hemispheres are simultaneously involved, and that
Examination (MMSE), has been developed to screen musical stimuli are capable of eliciting both right and
and monitor the progression of Alzheimer's disease. left ear superiority. Similarly, when people listen to
As a clinical instrument it is widely used and well and perform music they utilize differing hemispheric
validated in practice. As a bed-side test the MMSE processing strategies.
is widely used for testing cognition and is useful Evidence of the global strategy of music processing
as a predictive tool for cognitive impairment and in the brain is found in the clinical literature. In two
semantic memory without being contaminated by cases of aphasia3 singing was seen as a welcome
motor and sensory deficits. The items which the release from the helplessness and a means to
MMSE fails to discriminate (minor language deficits), communicate thoughts externally. Berman4 suggests
or neglects to assess (fluency and intentionality) may that recovery from aphasia is not a matter of new
be elicited in the playing of improvised music. A learning by the non-dominant hemisphere but a
dynamic musical assessment of patient behaviour, taking over of responsibility for language by that
linked with the motor co-ordination and intent hemisphere. The non-dominant hemisphere may be
required for the playing of musical instruments used a reserve of functions in case of regional failure.
in music therapy, and the necessary element of Little is known about the loss of musical and
interpersonal communication,may provide a sensitive language abilities in cases of global cortical damage.
complementary tool for assessment1. Any discussion is necessarily limited to hypothesiz-
ing as there are no established baselines for musical
Music and dementia performance in the adult population. Aphasia, which
Late in adult life, at the age of 56 years, and after is a feature of cognitive deterioration, is a complicated
David Aldridge
completing Collected
two major concertos for the music therapy
piano Maurice papers While syntactical functions may remain
phenomenon. 44
94 Journal of the Royal Society of Medicine Volume 86 February 1993

Table 1. Features of medical assessment and musical assessment

Medical elements of assessment Musical elements of assessment Examples of improvised playing

Continuing observation of Continuing observation of mental ¥Improvisationusing rhythmic instruments


mental and functional status and functional status (drum and cymbal) singly or in combination,
Â¥improvisationusing melodic instruments
Â¥singin and playing folk songs with harmonic
accompaniment

Testing of verbal skills, Testing of musical skills; rhythm, ¥playin tuned percussion (metallophone,
including element of speech melody, harmony, dynamic, xylophone, chime bars) demanding precise
fluency phrasing, articulation movements

Cortical disorder testing; visuo- Cortical disorder testing; visuo- ¥alternat playing of cymbal and drum using a
spatial skills and ability to spatial skills and ability to beater in each hand
perform complex motor tasks perform complex motor tasks ¥co-ordinate playing of cymbal and drum using
(including grip and right left (including grip and right left a beater in each hand
co-ordination). co-ordination). ¥co-ordinate playing of tuned percussion

Testing for progressive memory Testing for progressive memory ¥th playing of short rhythmic and melodic
disintegration disintegration phrases within the session, and in successive
sessions

Motivation to complete tests, to Motivation to sustain playing ¥th playing of a rhythmic pattern deteriorates
achieve set goals and persevere improvised music, to achieve when unaccompanied by the therapist, as does
in set tasks musical goals and persevere in the ability to complete a known melody,
maintaining musical form although tempo remains
'Intention' difficult to assess; 'Intention' a feature of improvised ¥th patient exhibits the intention to play the
but considered important musical playing piano from the onset of therapy and maintains
this intent throughout the course of treatment

Concentration and attention Concentration on the improvised ¥th patient loses concentration when playing,
span playing and attention to the with qualitative losses in the musical playing
instruments and lack of precision in the beating of
rhythmical instruments

Flexibility in task switching Flexibility in musical (including ¥initiall the musical playing is limited to a
instrumental) changes tempo of 120 bpm and a characteristic pattern
but this is responsive to change

Mini-mental state score Ability to play improvised music malthough the patient has a musical
influenced by educational status influenced by previous musical background this is only of help when she
training perceives the musical playing, it is little
influence in the improvised playing

Insensitive to small changes Sensitive to small changes ¥musicachanges in tempo, dynamic, timbre
and articulation which a t first are missing are
gradually developed

Ability to interpret Ability to interpret musical ¥th patient develops the ability to play in a
surroundings context and assessment of musical dialogue with the therapist
communication i n the demanding both a refined musical perception
therapeutic relationship and the ability of musical production

longer, it is the lexical and semantic functions of The patient often spontaneously sang without error
naming and reference which begin to fail in the early in pitch, melody, rhythm and lyrics, and spent long
stages. Phrasing and grammatical structures remain periods of time listening to music. Beatty6 describes
giving an impression of normal speech, yet content a woman who had severe impairments in terms of
becomes increasingly incoherent. These progressive aphasia, memory dysfunction and apraxia yet was
failings appear to be located within the context of able to sight read an unfamiliar song and perform on
semantic and episodic memory loss illustrated by the the xylophone which to her was an unconventional
inability to remember a simple story when tested. instrument. Like Ravel, she no longer recalled the
Musicality and singing are rarely tested as features name of the music she was playing.
of cognitive deterioration, yet preservation of these Swartz and his colleagues7 propose a series of
abilities in aphasics has been linked to eventual perceptual levels at which musical disorders take
recovery, and could be significant indicators of hier- place:
archical changes in cognitive functioning. Jacome5 (i) the acoustico-psychologicallevel, which includes
found that a musically naive patient with transcortical changes in intensity, pitch and timbre.
mixed aphasia exhibited repetitive, spontaneous (ii) the discriminatory level, which includes the
David Aldridge
whistling and whistling in response Collected music therapy papers of intervals and chords.
to questions. discrimination 45
Journal of the Royal Society of Medicine Volume 86 February 1993 95

(iii) the categorical level which includes the categorical structure which begins to fail in Alzheimer patients.
identification of rhythmic patterns and intervals. A loss of rhythmical context would explain why
(iv) the configural level, which includes melody patients are able to produce and persevere with
perception, the recognition of motifs and themes, tonal rhythmic and melodic playing when offered an overall
changes, identification of instruments, and rhythmic structure by the therapist, and would suggest a global
discrimination. failing in cognition while localized lower abilities are
(v) the level where musical form is recognized, retained.
including complex perceptual and executive functions Music therapy appears to offer a sensitive assessment
of harmonic, melodic and rhythmical transformations. tool. It tests those prosodic elements of speech produc-
In Alzheimer's patients it would be expected that tion which are not lexically dependent. Furthermore,
while levels (i), (ii) and (iii) remain unaffected, the it can be used to assess those areas of functioning,
complexities of levels (iv) and (v), when requiring no both receptive and productive, not covered adequately
naming, may be preserved but are susceptible to by other test instruments; ie fluency, perseverance in
deterioration. context, attention, concentration and intentionality.
It is perhaps important to point out that these In addition it provides a form of therapy which may
disorders are not themselves musical, they are dis- stimulate cognitive activities such that areas subject
orders of audition. Only when disorders of musical to progressive failure are maintained. Certainly the
production take place can we begin to suggest that anecdotal evidence suggests that quality of life of
a musical disorder is present. Improvised musical Alzheimer patients is significantly improved with
playing is in a n unique position to demonstrate this music therapy accompanied by the overall social
hypothetical link between perception and production. benefits of acceptance and sense of belonging gained
Descriptions of musical perception emphasize the by communicating with others. Prinsley recommends
importance of context where different levels of music therapy for geriatric care i n that it reduces the
attention occurring simultaneously against a back- individual prescription of tranquilizing medication,
ground temporal structure. Musical improvisation reduces the use of hypnotics on the hospital ward and
with a therapist, which emphasizes attention to the helps overall rehabilitation. He recommends that
environment utilizing changes in tempo and volitional music therapy be based on treatment objectives; the
response, without regard for lexical content, may be social goals of interaction co-operation; psychological
an ideal medium for treatment initiatives with goals of mood improvement and self-expression; intel-
Alzheimer's patients. The playing of simple rhythmic lectual goals of the stimulation of speech and
patterns and melodic phrases by the therapist, and organization of mental processes; and the physical
the expectation that the patient will copy those goals of sensory stimulation and motor integration8.
patterns or phrases, is similar to the element of The understanding of musical production may well
'registration' in the mental state examination. offer a clue to the ground structure of language and
While improvised musical playing is a useful tool communication in general. It is research in this realm
for the assessment of musical abilities, it is also used of perception which is urgent not only for the under-
within a therapeutic context. In this way assessment standing of Alzheimer's patients but in the general
and therapy are interlinked; assessment providing the context of cognitive deficit and brain behaviour.
criteria from which to identify therapeutic goals and
develop therapeutic strategies. Acknowledgment: The author would like to thank the music
If we are unsure as to the normal process of cog- therapist Gudrun Aldridge for access to the audio-tape
nitive loss in aging, we are even more in the dark recording of her clinical work, and her clinical insights into
as to the normal musical playing abilities of adults. working with the elderly.
The literature suggests that musical activities are pre-
served while other cognitive functions fail. Alzheimer References
patients, despite aphasia and memory loss, continue 1 Aldridge D. Music, communication and medicine: dis-
cussion paper. J R Soc Med 1989;82:743-6
to sing old songs and to dance to past tunes when
2 Gates A, Bradshaw J. The role of the cerebral hemi-
given the chance. However, the production of music, spheres in music. Brain Lung 1977;4:403-31
and the improvisation of music appears to fail in the 3 Morgan 0, Tilluckdharry R. Presentation of singing
same way in which language fails. Unfortunately no function in severe aphasia. West Indian Med J 1982;
established guidelines as to the normal range of 31:159-61
improvised music playing of adults is available. 4 Berman I. Musical functioning, speech lateralization and
Improvised music therapy in our experience appears the amusias. S Afi Med J 1981;59:78-81
to offer the opportunity to supplement mental state 5 Jacome D. Aphasia with elation, hypermusia, musicophilia
examinations in areas where those examinations are and compulsive whistling. J Neurol Neurosurg Psychiatry
lacking (Table 1). First, it is possible to ascertain the 1984;47:308-10
6 Beatty WW, Zavadil KD, Bailly RC, et aL Preserved
fluency of musical production. Second, intentionality, musical skills in a severely demented patient. Znt J Clin
attention to, concentration on and perseverance with Neuropsychol 1988;10:158-64
the task in hand are important features of producing 7 Swartz K, Hantz E, Crummer G, Walton J, Frisina R. Does
musical improvisations and susceptible to being heard the melody linger on? Music cognition in Alzheimer's
in the musical playing. Third, episodic memory can disease. Semin Neurol 1989;9:152-8
be tested in the ability to repeat short rhythmic and 8 Prinsley D. Music therapy in geriatric care. Aust Nurses
melodic phrases. The inability to build such phrases J 1986;15(9):48-9
may be attributed to problems with memory or to a
yet unknown factor. This unknown factor is possibly An extended list of references can be obtained from
involved with the organization of time structures. If the author.
rhythmic structure is a n overall context for musical
production, and the ground structure for perception1,
itDavid
can beAldridge
hypothesized that it is thisCollected music therapy
overarching (Acceptedpapers
30 December 1991) 46
Journal of Clinical Gempsychologv, Vol. 4, No. l, 1998

Music Therapy and the Treatment of Alzheimer's


Disease
David ,41dridge1

Ahheimer patients, despite aphasia and memory loss, continue to sing old songs and
to dance to past tunes when given the chance. Quality of life expectations become
paramount in any management strategy, and music therapy appears to play an impor-
tant role in enhancing the ability to actively take part in daily life. Improvised music.
therapy appears to offer the opportunity to supplement mental state examinations in
areas where those examinations are lacking. It is possible to ascertain the fluency of
musical production, perseverance with the task in hand, and episodic memory. The
inability to build phrases may be attributed to problems with memory or to an yet
unknown factor. This unknown factor is possibly involved with the organization of time
structures. Thus, music therapy offers an assessment tool sensitive to small changes.
Certainly, the anecdotal evidence suggests that quality of life of Ahheimers patients is
significantly improved with music therapy accompanied by the overall social benefits
of acceptance and sense of belonging gained by communicating with others.
KEY WORDS: rhythm; phrasing; intentionality; quality-of-life; music-therapy; memory.

INTRODUCTION

At the age of 56, the composer Maurice Ravel began to complain of increased
fatigue and lassitude. Following a traffic accident, his condition deteriorated pro-
gressively (Henson, 1988). He lost the ability to remember names, to speak spon-
taneously, and to write (Dalessio, 1984). Although he could understand speech, he
was no longer capable of the coordination required to lead a major orchestra. While
his mind, he reports, was full of musical ideas, he could not set them down (Dales-
sio, 1984). Eventually, his intellectual functions and speech deteriorated until he
could no longer recognize his own music. We would speculate now that he had
been suffering from Alzheimer's disease.
In this paper; the value of music for the sufferers of Alzheimer's disease will
be discussed. In particular, there will be a focus on music as therapy.
'~edizinische Fakultat, Universitat Witten Herdecke, Alfred Herrhausen Stra. 50, 58448 Witten,
Germany.

David Aldridge . therapy papers


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18 Aldridge

MUSIC AS THERAPY
There are two principal ways of doing music therapy: "active music therapy"
which requires that the patient, or a group of patients play musical instruments, or
sing, with the therapist; and, "passive music therapy" whereby the patient, or a
group of patients, listen to the therapist who plays live, or recorded, music to them.
In active music therapy, the music is often improvised to suit the individual patient.
In passive music therapy, the music is often chosen to suit particular patients.
Within each of these two main approaches, there are varying schools throughout
the Western world, some based on the work of particular teachers, and some are
more eclectic and based on psychotherapeutic approaches. Music therapy has been
reviewed in the medical and nursing press and the principle emphasis is on the
soothing ability of music and the necessity of music as an antidote to an overly
technological medical approach. Most of these articles are concerned with passive
music therapy and the playing of pre-recorded music to patients emphasizing the
necessity of healthy pleasures like music, fragrance, and beautiful sights for the
reduction of stress and the enhancement of well-being. The overall expectation is
that the recreational, emotional, and physical health of the patient is improved
(Aldridge, 1993b).
After the Second World War, however, music therapy was intensively developed
in American hospitals (Schullian and Schoen, 1948). Since then, some hospitals,
particularly in mainland Europe, have incorporated music therapy carrying on a
tradition of European hospital-based research and practice (Aldridge, 1990;
Aldridge, Brandt, and Wohler, 1989). In recent years, there has been a move to
develop an academic tradition of research that attempts to begin a clinical dialogue
with other practitioners through research practice (Aldridge, 1989, 1991a,b, 1993a;
Aldridge, Gustorff, and Hannich, 1990).

MUSIC, COGNITION AND LANGUAGE

As in Ravel's demise above, the responsiveness of patients with Alzheimer's


disease to music is a remarkable phenomenon (Swartz, Hantz, Crummer, Walton,
and Frisina, 1989). While language deterioration is a feature of cognitive deficit,
musical abilities appear to be preserved. This may be because the fundamentals of
language, as we have seen in previous chapters, are musical, and prior to semantic
and lexical functions in language development.
Although language processing may be dominant in one hemisphere of the brain,
music production involves an understanding of the interaction of both cerebral hemi-
spheres (Altenmuller, 1986; Brust, 1980; Gates and Bradshaw, 1977). In attempting
to understand the perception of music, there have been a number of investigations
into the hemispheric strategies involved. Much of the literature considering musical
perception concentrates on the significance of hemispheric dominance. Gates and
Bradshaw (1977J'conclude that cerebral hemispheres are concerned with music per-
ception and that no laterality differences are apparent. Other investigators (Wagner
and Hannon, 1981) suggest that two processing functions develop with training where

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Music Therapy and Treatment of Alzheimer's Disease 19

left and right hemispheres are simultaneously involved, and that musical stimuli are
capable of eliciting both right and left ear superiority (Kellar and Bever, 1980). Simi-
larly, when people listen to and perform music, they utilize differing hemispheric
processing strategies.
Evidence of the global strategy of music processing in the brain is found in
the clinical literature. In two cases of aphasia (Morgan and Tilluckdhany, 1982),
singing was seen as a welcome release from the helplessness of being a patient.
The authors hypothesized that singing was a means to communicate thoughts ex-
ternally. Although the "newer aspect" speech was lost, the older function of music
was retained possibly because music is a function distributed over both hemispheres.
Berman (1981) suggests that recovery from aphasia is not a matter of new learning
by the nondominant hemisphere but a taking over of responsibility for language by
that hemisphere. The nondominant hemisphere may be a reserve of functions in
case of regional failure.
Little is known about the loss of musical and language abilities in cases of
global cortical damage, although the quality of response to music in the final stages
of dementia is worth noting (Norberg, Melin, and Asplund, 1986). Any discussion
is necessarily limited to hypothesizing as there are no established baselines for mu-
sical performance in the adult population (Swartz et al., 1989). Aphasia, which is
a feature of cognitive deterioration, is a complicated phenomenon. While syntactical
functions may remain longer, it is the lexical and semantic functions of naming and
reference which begin to fail in the early stages. Phrasing and grammatical struc-
tures remain giving an impression of normal speech, yet content becomes increas-
ingly incoherent. These progressive failings appear to be located within the context
of semantic and episodic memory loss illustrated by the inability to remember a
simple story when tested (Bayles et aL, 1989).
Musicality and singing are rarely tested as features of cognitive deterioration,
yet preservation of these abilities in aphasics has been linked to eventual recovery
(Jacome, 1984; Morgan and Tilluckdhany, 1982), and could be significant indica-
tors of hierarchical changes in cognitive functioning. Jacome (1984) found that a
musically naive patient with transcortical mixed aphasia exhibited repetitive, spon-
taneous whistling and whistling in response to questions. The patient often spon-
taneously sang without error in pitch, melody, rhythm, and lyrics, and spent long
periods of time listening to music. Beatty et al. (1988) describe a woman who had
severe impairments in terms of aphasia, memory dysfunction, and apraxia; yet, she
was able to sight read an unfamiliar song and perform on the xylophone which
to her was an unconventional instrument. Like Ravel (Dalessio, 1984), an elderly
musician who could play from memory (Crystal, Grober, and Masur, 1989) no
longer recalled the name of the composer, she no longer recalled the name of
the music she was playing.
Swartz et aL (1989) propose a series of perceptual levels at which musical dis-
orders take place: (1) the acoustico-psychological level, which includes changes in
intensity, pitch, and timbre; (2) the discriminatory level, which includes the dis-
crimination of intervals and chords; (3) the categorical level, which includes the
categorical identification of rhythmic patterns and intervals; (4) the configural level,
which includes melody perception, the recognition of motifs and themes, tonal

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20 Aldridge

changes, identification of instruments, and rhythmic discrimination; (5) the level


where musical form is recognized, including complex perceptual and executive func-
tions of harmonic, melodic, and rhythmical transformation.
In Alzheimer's patients, it would be expected that while levels (l), (2), and
(3) remain unaffected, the complexities of levels (4) and (5) when requiring no
naming, may be preserved but are susceptible to deterioration.
It is perhaps important to point out that these disorders are not themselves
musical, they are disorders of audition. Only when disorders of musical production
take place can we begin to suggest that a musical disorder is present. Improvised
musical playing is in an unique position to demonstrate this hypothetical link be-
tween perception and production. Rhythm is the key to the integrative process un-
derlying both musical perception and physiological coherence. When considering
communication, rhythm is also fundamental to the organization and coordination
of internal processes, and externally between persons (Aldridge, 1989). Rhythm of-
fers a frame of reference for perception (Povel, 1984).
Rhythm too plays a role in the perception of melody. The perceptions of
speech and music are formidable tasks of pattern perception. The listener has to
extract meaning from lengthy sequences of rapidly changing elements distributed
in time (Morrongiello, Ti-ehub, Thorpe, and Capodilupo, 1985). amporal predict-
ability is important for tracking melody lines (Jones, Kidd, and Wetzel, 1981; Kidd,
Boltz, and Jones, 1984). Kidd et a i (1984) also refer to melody as having a structure
in time and that a regular rhythm facilitates the detection of a musical interval and
its subsequent integration into a cognitive representation of the serial structure of
the musical pattern. Adults identify familiar melodies on the basis of relational in-
formation about intervals between tones rather than the absolute information of
particular tones. In the recognition of unfamiliar melodies, less precise information
is gathered about the tone itself. The primary concern is with successive frequency
changes or melodic contour. The rhythmical context prepares the listener in ad-
vance for the onset of certain musical intervals and therefore a structure from which
to discern, or predict, change. One may not be aware of certain changes and become
either out of tune or out of time; such a loss of rhythmical structure, which appears
outwardly as confusion, may be a hidden factor in the understanding of Alzheimer's
disease.
What is important in these descriptions of musical perception is the emphasis
on context where there are different levels of attention occurring simultaneously
against a background temporal structure (Jones et al., 1981; Kidd et a i , 1984). Mu-
sical improvisation with a therapist, which emphasizes attention to the environment
(Sandman, 1984; Walker and Sandman, 1979; Walker and Sandman, 1982) utilizing
changes in tempo and volitional response (Safranek, Koshland, and Raymond,
1982), without regard for lexical content, may be an ideal medium for treatment
initiatives with Alzheimer's patients. The playing of simple rhythmic patterns and
melodic phrases by the therapist, and the expectation that the patient will copy
those patterns or-phrases, is similar to the element of "registration" in the mental
state examination.
While improvised musical playing is a useful tool for the assessment of musical
abilities, it is also used within a therapeutic context. In this way, assessment and

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Music Therapy and Treatment of AJzheimer's Disease 21

therapy are interlinked; assessment providing the criteria from which to identify
therapeutic goals and develop therapeutic strategies.

MUSIC THERAPY AND THE ELDERLY

Much of the published work concerning music therapy with the elderly is con-
cerned with group activity (Bryant, 1991; Christie, 1992; Olderog Millard and Smith,
1989) and is generally used to expand socialization and communication skills, with
the intention of reducing problems of social isolation and withdrawal, to encourage
participants to interact purposefully with others, assist in expressing and commu-
nicating feelings and ideas, and to stimulate cognitive processes, thereby sharpening
problem-solving skills. Additional goals also focus on sensory and muscular stimu-
lation and gross and fine motor skill development (Segal, 1990).
Clair (1990a,b) has worked extensively with tlie elderly and found music ther-
apy a valuable tool for working in groups to promote communicating, watching
others, singing, interacting with an instrument, and sitting. Her main conclusions
are that although the group members deteriorated markedly in cognitive, physical,
and social capacities over an observation period of 15 months, they continued to
participate in music activities. During the 30-minute sessions, group members con-
sistently sat in chairs without physical restraints for the duration of each session
and interacted with others regardless of their deterioration. This was the only time
in the week when they interacted with others (Clair and Bernstein, 1990b). Indeed
for one 66-year-old man, it is the sensory stimulation of music therapy that brought
him out of his isolation such that he could participate with others, even if for a
short while (Clair, 1992).
Wandering, confusion and agitation are associated problems common to elderly
patients living in hostels or special accommodations for Alzheimers' patients. A
music therapist (Cloutier, 1993) has tested singing with the an 81-year-old woman
to see if it helped her to remain seated. After 20 singing sessions, the therapist
read to the woman to compare the degree of attentiveness. While music therapy
and reading sessions redirected the subject from wandering, the total time she sat
for the music therapy sessions was double that of the reading sessions (214.3 min
vs. 99.1 min), and the time spent seated in the music therapy was more consistent
than the sporadic episodes when she was being read to. When agitation occurs in
such elderly women, then individualized music therapy appears to have a signifi-
cantly calming effect (Gerdner and Swanson, 1993). In terms of reducing repetitive
behavior, musical activity also reduces disruptive vocalizations (Casby and Holm,
1994).
The above conclusions are supported by Groene (1993). Thirty residents (aged
60-91 years) of a special Alzheimer's unit,'who exhibited wandering behavior, were
randomly assigned to either mostly music attention or mostly reading attention
groups where they received one-to-one attention. Those receiving music therapy
remained seated longer than those in the reading sessions.
One of the central problem of the elderly is the loss of independence and
self-esteem, and Palmer (1977, 1983, 1989) describes a program of music therapy

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at a geriatric home designed to rebuild self-concept. For the 380 residents, ranging
from those who were totally functional to those who needed total care, a program
was adapted to the capacities and needs of individual patients. Marching and danc-
ing increased the ability of some patients to walk well; and for the nonambulatory,
kicking and stamping to music improved circulation and increased tolerance and
strength. Sing-along sessions were used to encourage memory recall and promoted
social interaction and appropriate social behavior (Palmer, 1983, 1989). It was such
social behavior that Pollack and Namazi (1992) report as being accessible to im-
provement through group music therapy activities. It is the partcipative element,
that appears to be valuable for communication, and the intention to participate
that is at the core of the music therapy activity which we will see in the following
section.
Music therapy has also been used to focus on memory recall for songs and
the spoken word (Prickett and Moore, 1991). In ten elderly patients, whose diag-
nosis was probably Alzheimer's disease, words to songs were recalled dramatically
better than spoken words or spoken information. Although long-familiar songs were
recalled with greater accuracy than a newly presented song, most patients attempted
to sing, hum, or keep time while the therapist sang. However, Smith (1991) suggests
that it is factors such as tempo, length of seconds per word, and total number of
words that might be more closely associated with lyric recall than the relative fa-
miliarity of the song selection.
In a further study of the effects of three treatment approaches (musically cued
reminiscence, verbally cued reminiscence, and music alone) on the cognitive func-
tioning of 12 female nursing home residents with Alzheimer's Disease, changes in
cognitive functioning were assessed by the differences between pre- and postsession
treatment scores on the Mini-Mental State Examination. Comparisons were made
for total scores and subscores for orientation, attention, and language. Musically
cued and verbally cued reminiscence significantly increased language subsection
scores and musical activity alone significantly increased total scores (Smith, 1986).
Prinsley (1986) recommends music therapy for geriatric care as it reduces the
individual prescription of tranquilizing medication, reduces the use of hypnotics on
the hospital ward, and helps overall rehabilitation. He recommends that music ther-
apy be based on treatment objectives, the social goals of interaction cooperation,
psychological goals of mood improvement and self-expression, intellectual goals of
the stimulation of speech and organization of mental processes, and the physical
goals of sensory stimulation and motor integration. Such goals as stimulation of
the individual, promoting involvement in social activity, identifying specific indi-
vidualized behavioral targets, and emphasizing the maintenance of specific memory
functions is repeated throughout the music therapy literature (Prange, 1990; Smith,
S., 1990, 1991). Similarly, Smith, D. S. (1990) recommends behavioral interventions
targeted at the more common behavioral problems (e.g., disorientation, age-related
changes in social activity, sleep disturbances) of institutionalized elderly persons.
In a study of mu& therapy in two nursing homes, life satisfaction and self-esteem
were significantly improved in the home where the residents participated in the
musical activities in comparison with a matched control group that had no music
therapy (VanderArk, Newman, and Bell, 1983).

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Music Therapy and Treatment of Alzheimer's Disease 23

MUSIC THERAPY WITH AN ALZHEIMER'S PATIENT- A CASE STUDY

In improvised music therapy, the music therapist plays the piano improvising
with the patient who uses a range of instruments and voice. This work often begins
with an explanatory session using rhythmic instruments, in particular the drum and
cymbal; progressing to the use of rhythmic/melodic instruments such as the chime
bars, glockenspiel or xylophone; developing into work with melodic instruments (in-
cluding the piano); and the voice. An emphasis is placed on a series of musical
,improvisations during each session, and music is the vehicle for the therapy. Each
session is audiotape-recorded, with the consent of the patient, and later analyzed
andindexed as to the musical content. No musical training is required of the patient
although it is essential to discover the musical background of the patient. They are
asked about to which music they like to listen, and perhaps more importantly, to
which music did they dance when they were younger.
A 55-year-old female patient came to outpatient treatment at a general hospital
for ten weekly sessions. Each session lasted 40 minutes. Her son drove her to each
session as she was unable to find her way alone using public transport. Her sister
had died with Alzheimer's disease and the family were concerned that she too was
repeating her sister's demise. Her memory had begun to fail and she became in-
creasingly disturbed. The patient was referred initially to the hospital when she,
and her son, became aware of her own deteriorating condition. At home, she was
experiencing difficulties in finding items of clothing and other things necessary for
everyday life. She could not cook for herself anymore and was unable to write her
own name. While wanting to speak, she experienced difficulty in finding words. She
also appeared to be depressed, and in the light of her sister's death, and her own
knowledge regarding her current predicament, it seemed reasonable to make this
assumption. As she had previously played the piano for family and friends, although
without any formal training, music therapy appeared to have potential as an inter-
vention adjuvant to her medical treatment.
In all ten sessions, she demonstrated her ability to play a singular ordered
rhythmic pattern in 414 time using two sticks on a drum. However, a feature of her
rhythmical playing was that in nearly all the sessions, the patient would let control
of the rhythmic pattern slip such that it became progressively imprecise, losing both
its form and liveliness. The initial impulse of her rhythmical playing, which was
clear and precise, gradually deteriorated as she lost concentration and ability to
persevere with the task in hand. However, when the therapist offered an overall
musical structure during the course of the improvisation, by playing herself a known
piece of music, then the patient could regain her precision of rhythm.
In the rhythmical playing on drum and cymbal, the therapist attempted to de-
velop the patient's attention span through the use of short repeated musical patterns
and changes in key, volume and tempo. She hoped that through changes in the
sound to steer the patient to maintaining a stable musical form. This technique
helped the to maintain a rhythmical pattern and brought her to the stage
which she could express herself stronger musically. The therapist also searched for
other ways to develop variety in rhythm by moving away rom the repetitive pattern
played by this patient.

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A change in the patient's ability to improvise was shown when the patient rec-
ognized, and could repeat rhythmical patterns in a musical dialogue and thereby
brought into a musical context. In the last session of therapy, the patient was able
to change her playing in this way such that she could express more strongly by
bringing into line her thoughtful and expressive playing. It was this ability to become
rhythmically flexible when brought into the form of a dialogue that is a fundamental
feature of encouraging communicational competence.
From the first session of therapy, the patient made it quite clear her own intent
to sit at the piano and play whatever melodies she chose and to find the appropriate
accompaniments. This wish and the corresponding willpower to achieve this end,
was shown in all the sessions. It was possible to use this impetus to play as a source
for improvisation. She laughed with joy at the success of playing and often asked
to repeat a successful accomplishment. Lapses and slips in her rhythmical playing
could be carried by the intent and expression with which she played. While her
overall intention to play was preserved, her attention to that playing, the concen-
tration necessary for musical production and the perseverance required for com-
pleting a sequence of phrases progressively failed and was dependent on the overall
musical structure offered by the therapist.
At the end of the treatment period, she was able to cook for herself and could
find her own things about the house. The psychiatrist responsible for her therapeutic
management reported an overall improvement in her interest in what was going
on around her, and in particular that she maintained attention to visitors and con-
versations. The patient regained the ability to sign her name, although she could
only write slowly. While wanting to speak, she still experienced difficulty in finding
words.
It appears that music therapy had a beneficial effect on the quality of life for
this patient, and that some of the therapeutic effect may have been brought about
by handling the depression associated with her failing cognitive abilities and the
forebodings of a future reflecting her sister's fate. While the patient came to the
sessions with the intention of playing, her ability to take initiatives was impaired,
mirroring the state of her home life where she wanted to look after herself, yet
was unable to take initiatives. This stimulus to take initiatives in the music was
seen as an important feature of the music therapy by the therapist and appears to
have a correlate in the way in which the patient began to take initiatives in her
daily life.
Active music-making promotes interaction between the persons involved,
thereby promoting initiatives in communication. Furthermore, the implications for
the maintenance of memory by actively making music is significant. As Crystal et
al. (1989) found in an 82-year-old musician with Alzheimer's disease, there was a
preserved ability to: (1) play previously learned piano compositions from memory,
although the man was unable to identify the composer or titles of each work, and
(2) learn the new skill of mirror reading while being unable to recall or recognize
new information.'This woman could remember some old songs, but also learned
new melodies arid retained them from session to session.
A contraindication for music therapy with such patients who are aware of their
problems is that the awareness of further cognitive abilities as experienced in the

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Music Therapy and Treatment of Alzheimer's Disease 25

"fable I. Features of Medical and Musical Assessment


Medical elements of assessment Musical elements of assessment
Continuing observation of mental and Continuing observation of mental and
functional status functional status
Testing of verbal skills, including element of Testing of musical skills; rhythm, melody,
speech fluency harmony, dynamic, phrasing, articulation

Cortical disorder testing; visuospatial skills Cortical disorder testing; visuospatial skills
and ability to perform complex motor tasks and ability to perform complex motor tasks
(including grip and right left coordination). (including grip and right left coordination).
Testing for progressive memory disintegration Testing for progressive memory disintegration

Motivation to complete tests, to achieve set Motivation to. sustain playing improvised
goals and persevere in tests music, to achieve musical goals and
persevere in maintaining musical form
"Intention" difficult to assess; but considered "Intention" a feature of improvised musical
important playing
Concentration and attention span Concentration on the improvised playing and
attention to the instruments

Flexibility in task switching Flexibility in musical (including instrumental)


changes
Mini-mental state score influenced by Ability to play improvised music influenced
educational status by previous musical training
Insensitive to small changes Sensitive to small changes
Ability to interpret surroundings Ability to interpret musical context and
assessment of communication in the
therapeutic relationship

playing may exacerbate any underlying depression and demotivate the patient to
continue. For this patient, she was painfully aware that she could no longer find
the harmonies with her left had required for the accompaniment of her favorite
songs. This too was another sign of her failing cognitive ability. However, what
appeared to be of value from the music therapy sessions (as can be seen in Tables
I and 11) is that active musical playing provides a basis from which assessments of
varying competencies can be made. Not only is it possible to discern a variety of
motor abilities and cognitive competencies, including episodic memory, there is the
further advantage of assessing intentionality and perseverance throughout episodes
of playing and the session itself. This form of assessment is not based on a verbal
competence; and furthermore, the patient is not aware that she is being tested.

CONCLUSION

Alzheimer patients, despite aphasia and memory loss, continue to sing old
songs and to dance to past tunes when given the chance. Indeed, fun and enter-

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Table 11. Musical Elements of Assessment and Examples of Improvised Playing
Musical elements of assessment Examples of improvised playing
0 Testing of musical skills; rhythm, melody, Improvisations using rhythmic instruments
harmony, dynamic, phrasing, articulation (drum and cymbal) singly or in combination
0 Improvisations using melodic instruments

Singing and playing folk songs with harmonic


accompaniment

0 Cortical disorder testing; visuospatial skills Playing tuned percussion (metallophone,


xylophone, chime bars) demanding precise
movements
Cortical disorder testing; ability to perform Alternate playing of cymbal and drum using a
complex motor tasks (including grip and right beater in each hand
left coordination) Coordinated playing of cymbal and drum using
a beater in each hand
Coordinated playing of tuned percussion

0 Testing for progressive memoxy disintegration 0 The playing of short rhythmic and melodic
phrases within the session, and in successive
sessions
Motivation to sustain playing improvised The playing of a rhythmic pattern deteriorates
music, to achieve musical goals and persevere when unaccompanied by the therapist, as does
in maintaining musical form the ability to complete a known melody,
although tempo remains
"Intention" a feature of improvised musical The patient exhibits the intention to play the
playing piano from the onset of therapy and maintains
this intent throughout the course of treatment

Concentration on the improvised playing and The patient loses concentration when playing,
attention to the instruments with qualitative loss in the musical playing and
lack of precision in the beating of rhythmical
instruments
Flexibility in musical (including instrumental) Initially the musical playing is limited to a
changes tempo of 120 Bp and a characteristic pattern
but this is responsive to change
Ability to play improvised music influenced Although the patient has a musical
by previous musical training background this is only of help when she
perceives the musical playing, it is little
influence in the improvised playing

Sensitive to small changes Musical changes in tempo, dynamic, timbre,


and articulation which at first are missing are
gradually developed

Ability to interpret musical context and The patient develops the ability to play in a
relationship musical dialogue with the therapist demanding
both a refined musical perception and the
ability of musical production

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Music Therapy and Treatment of Alzheimer's Disease 27

tainment are all part and parcel of daily living for the elderly living in special ac-
commodation (Glassman, 1983; Jonas, 1991; Kartman, 1990; Smith, 1992). Quality
of life expectations become paramount in any management strategy, and music ther-
apy appears to play and important role in enhancing the ability to actively take
part in daily life (Lipe, 1991; Rosling and Kitchen, 1992). However, the production
of music, and the improvisation of music, appears to fail in the same way in which
language fails.
Improvised music therapy appears to offer the opportunity to supplement men-
tal state examinations in areas where those examinations are lacking. First, it is
possible to ascertain the fluency of musical production. Second, intentionality, at-
tention to, concentration on, and perseverance with the task in hand are important
features of producing musical improvisations and susceptible to being heard in the
musical playing. Third, episodic memory can be tested in the ability to repeat short
rhythmic and melodic phrases. The inability to build such phrases may be attributed
to problems with memory or to an as-yet unknown factor. This unknown factor is
possibly involved with the organization of time structures. If rhythmic structure is
an overall context for musical production, and the ground structure for perception,
it can be hypothesized that it is this overarching structure which begins to fail in
Alzheimers patients. A loss of rhythmical context would explain why patients are
able to produce and persevere with rhythmic and melodic playing when offered an
overall structure by the therapist. Such a hypothesis would tie in with the musical
hierarchy proposed by ~wartz'(l989), and would suggest a global failing in cognition
while localized lower abilities are retained. However, the hierarchy of musical per-
ceptual levels proposed by Swartz may need to be further subdivided into classifi-
cations of music reception and music production.
Music therapy offers an assessment tool sensitive to small changes (see Tables
I and 11). It tests those prosodic elements of speech production which are not lexi-
cally dependent; that is, rhythm, melody, harmony, dynamic, phrasing, articulation.
Furthermore, it can be used to assess those areas of functioning, both receptive
and productive, not covered adequately by other test instruments (i.e., fluency, per-
severance in context, attention, concentration, and intentionality). In addition, it
provides a form of therapy which may stimulate cognitive activities such that areas
subject to progressive failure, as in progressive memory disintegration, are main-
tained. There is a possibility to promote both visuo-spatial skills needed in playing
instruments and the concentration needed to maintain that playing over a period
of time. The playing of instruments apart from its therapeutic value is enables an
assessment of grip strength and right-left coordination.
Certainly, the anecdotal evidence suggests that quality of life of Alzheimers
patients is significantly improved with music therapy (McCloskey, 1985, 1990; Tyson,
1989) accompanied by the overall social benefits of acceptance and sense of be-
longing gained by communicating with others (Morris, 1986; Segal, 1990).
Unfortunately, most of the literature concerning cognition and musical per-
ception is based.On audition and not musical production. Like other authors, we
suggest that the production of music, as is the production of language, a complex
global phenomenon as yet poorly understood. The understanding of musical pro-
duction may well offer a clue to the ground structure of language and communi-

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28 Aldridge

cation in general. It is research in this realm of perception which is urgent not only
for the understanding of Alzheimers patients but in the general context of cognitive
deficit and brain behavior. It may be as Berman (1981) suggests, that the nondomi-
nant hemisphere is a reserve of functions in case of regional failure and this func-
tionality can be stimulated to delay the progression of degenerative disease. We
may need to address in future research the coordinating role of rhythm in human
cognition and consciousness whether it be in persons who are losing cognitive abili-
ties, or in persons who are attempting to gain cognitive abilities.

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The Arts in Psychotherapy. Vol. 19, pp. 243-255, 1992 0197-4556192 $5.00 + .OO
Printed in the USA. All rights reserved. Copyright 0 1992 Pergamon Press Ltd.

TWO EPISTEMOLOGIES: MUSIC THERAPY AND MEDICINE IN THE


TREATMENT OF DEMENTIA

DAVID ALDRIDGE, PhD and GUDRUN ALDRIDGE, Dipl, MT*

In earlier papers it has been suggested that it is first histopathological characterizations of cognitive
possible for music therapists, creative arts therapists disorders were made possible by developments in the
and medical practitioners to work together so that they optical microscope. Thus, Alzheimer (1907) was able
may negotiate a common language (Aldridge & to see the neuronal degeneration and senile plaques in
Brandt, 1991; Aldridge, Brandt, & Wohler, 1989). the brain of a 55-year-old woman with progressive
This paper extends that debate further into another memory impairment and identify the disease that to-
clinical realm, that of dementia in the elderly. day bears his name.
Dementia is an important source of chronic dis- Although cognitive impairment is evident from be-
ability leading to both spiralling health care expendi- havior, and neurohistopathology can recognize neu-
ture among the elderly and a progressive disturbance ronal degeneration, the diagnosis of Alzheimer's dis-
of life quality for the patient and his or her family. In ease is prone to error, and authors differ as to the
the United States the cost of institutional care for difficulty of making a precise diagnosis (Odenheimer,
patients with dementia is estimated at over $25 billion 1989; Steg, 1990). In the early stages of the disease
a year (Steg, 1990). If 4% to 5% of the US elderly the symptoms are difficult to distinguish from those of
population suffer from dementia, then it can be esti- normal aging, a process that itself is poorly under-
mated that 1.25% of the adult population are suffering stood. To date, there exist no normative established
with the problems of severe dementia. Other esti- values of what is cognitive impairment or memory
mates of the same population suggest that 15% of loss, or what neurochemical and neurophysiological
those over the age of 65 will have moderate to severe changes accompany normal aging. It is, therefore,
dementia with projections to 45% by the age of 90 extremely difficult to establish criteria for determin-
years (Odenheimer, 1989). Current estimates are that ing abnormal changes from a normal population
over 60% of those cases of dementia result from Alz- and the researcherlclinician must in part rely upon
heimer's disease (Kalayam & Shamoian, 1990). within-the-subject designs to indicate progressive
Dementing illnesses, or acquired cognitive disor- deterioration.
ders, have been recognized for centuries, but little A second source of error in diagnosing Alzhei-
progress was made in specific diagnoses until the evo- mer's disease is that it is masked by other conditions
lution of the nosologic approach to disease and early (see Table 1). Principal among these conditions is that
clinical descriptions of neurosyphilis and Hunting- of depression, which itself can cause cognitive and
ton's chorea in the 1800s. Such descriptions were behavioral disorders. In addition, it is estimated that
further supported by concurrent understandings that 20% to 30% of patients with Alzheimer's disease will
suggested the influence of the brain on behavior. The have an accompanying depression (Kalayam & Sha-

*David Aldridge, a frequent contributor, is a research consultant to the medical faculty of Universitat Witten Herdecke, Germany and
European Editor of The Arts in Psychotherapy.
Gudrun Aldridge is a music therapist.

David Aldridge Collected music therapy papers 61


244 ALDRIDGE AND ALDRIDGE

Table 1 When such clinical findings are present, then a prob-


Differential Diagnosis of Alzheimer's Disease able diagnosis can be made; a more definite diagnosis
depends upon tissue diagnosis (see Table 2).
Differential Diagnosis Although dementia of the Alzheimer's type begins
after the age of 40, and is considered to be a disease
Multi-infarct dementia and other forms of cerebrovascular of the elderly, the influence of age on prognosis is not
disease as significant as the initial degree of severity of the
Parkinson's disease
problem when recognized (Drachman et al., 1990).
Progressive supranuclear palsy
Huntington's disease
Disease severity, as assessed by intellectual function,
Central nervous system infection appears to be the most consistent predictor of the
Subdural haematoma subsequent course of the disease, particularly when
Normal pressure hydrocephalus accompanied by a combination of wandering and fall-
Multiple sclerosis ing, and behavioral problems (Walsh, Welch, & Lar-
Seizure disorder son, 1990). However, the rates of decline between
Brain tumor subgroups of patients are variable and a patient's rate
Cerebral trauma of progression in one year may bear little relationship
Metabolic disturbance to future rate of decline (Salmon, Thai, Butters, &
Nutritional deficiency
Heindel, 1990). Some authors (Cooper, Mungas, &
Psychiatric disorder
Substance abuse or overmedication
Weiler, 1990) suggest that an as yet unproven factor,
other than declining cognitive ability, may also play a
Taken from Steg, R. 1990, Determining the cause of dementia. part in the associated abnormal behaviors of anger,
Nebraska Medical Journal, 75 (4). 59-63. Reprinted with permis- agitation, personality change, wandering, insomnia
sion. and depression, which occur in later stages of the
disease.
moian, 1990) thereby compounding diagnostic prob- Clearly, Alzheimer's disease causes distress for
lems further. the patient. The loss of memory and the accompany-
ing loss of language, before the onset of motor im-
Clinical Descriptions of Dementia pairment, means that the daily lives of patients are
disturbed. Communication, the fabric of social con-
The clinical syndrome of dementia is characterized tact, is interrupted and disordered. The threat of pro-
by an acquired decline of cognitive function that is gressive deterioration and behavioral disturbance has
represented by memory and language impairment. ramifications not only for the patients themselves, but
Whereas the term dementia itself is used widely also their families, who must take some of the social
throughout the medical literature, and in common us- responsibility for care of the patients and bear the
age, to describe cognitive impairment, it is generally
applied to two conditions: dementia of the Alzhei- Table 2
mer's type (DAT) and multi-infarct dementia. Diagnostic Evaluation of Dementia
The course of Alzheimer's disease is one of pro-
gressive deterioration associated with degenerative Diagnostic Categories
changes in the brain. Such deterioration is presented
in a clinical picture of episodic changes and a pattern Complete medical history
of particular cognitive failings that are variable Mental status examination
(Drachman, O'Donnell, Lew, & Swearer, 1990). Complete physical and neurological investigation (including
Mental status testing is one of the primary forms of investigation for infection of central nervous system if
assessing these cognitive failings, which include short suspected)
and long-term memory changes, impairment of ab- Complete blood count and blood chemistry tests (including
vitamin B 12 levels)
stract thinking and judgment, disorders of language
Thyroid function tests
(aphasia), and difficulty in finding the names of Serology for syphilis
words (anomia), the loss of ability to interpret what is Computerized tomography (CT) or magnetic resonance imaging
heard, said and felt (agnosia), and an inability to carry (MRI), electroencephalography (EEG), or positive emission
out motor activities, such as manipulating a pen or tomography (PET) scanning
toothbrush, despite intact motor function (apraxia).

David Aldridge Collected music therapy papers 62


TWO EPISTEMOLOGIES IN TREATMENT OF DEMENTIA 245

emotional burden of seeing a loved one becoming possible total score of 30 are considered demented.
confused and isolated. However, this scoring has been questioned on the
Finally, it must also be borne in mind that the grounds of its cut-off point of 24 as the lower limit,
elderly depressed can exhibit a pseudodementia particularly for early dementia (Galasko, Klauber,
(Caine, 1981) whereby Alzheimer's is mimicked (see Hofstetter, Salmon, Lasker, & Thai, 1990); and, that
Table 3). Such patients recover and show no sign of it is influenced by education (Gagnon et al., 1990).
residual intellectual impairment. Poorly educated subjects with less than eight years of
education may score below 24 without being
demented.
Assessment of Dementia Further criticisms of the Mini-Mental State Exam-
ination (MMSE) have been that it is not sensitive
A brief cognitive test, the Mini-Mental State Ex- enough to mild deficits, but it could be augmented by
amination (Folstein, Folstein, & McHugh, 1975), has the addition of a word fluency task and an improve-
been developed to screen and monitor the progression ment in the attention-concentration item (Galasko et
of Alzheimer's disease. The test itself is intended for al., 1990). In addition, the MMSE seriously under-
the clinician to assess functions of different areas of estimates cognitive impairment in psychiatric patients
the brain, and is based upon questions and activities (Faustman, Moses, & Csemansky, 1990). An impor-
(see Table 4). As a clinical instrument it is widely tant feature neglected by the MMSE is that of "in-
used and well validated in practice (Babikian, Wolfe, tention" or executive control (Odenheimer, 1989),
Linn, Knoefel, & Albert, 1990; Beatty & Goodkin, which refers to the ability of the patient to persevere
1990; Eustache, Cox, Brandt, Lechevalier, & Pons, with a set task, to reach a set goal or to change tasks.
1990; Faustman, Moses, & Csemansky, 1990; Gag- The items the MMSE fails to discriminate (minor
non, Letenneur, Dartigues, Commenges, Orgogozo, language deficits), or neglects to assess (fluency and
Gateau, Alperovitch, Decamps, & Salamon, 1990; intentionality), however, may be elicited in the play-
Jairath & Campbell, 1990; Summers, DeBoynton, ing of improvised music. A dynamic musical assess-
Marsh, & Majovski, 1990; Zillmer, Fowler, Gutnick, ment of patient behavior, linked with the motor co-
& Becker, 1990). A bedside test, the MMSE is ordination and intent required for the playing of mu-
widely used for testing cognition and is useful as a sical instruments used in music therapy, and the
predictive tool for cognitive impairment and semantic necessary element of interpersonal communication,
memory (Eustache et al., 1990) without being con- may provide a sensitive complementary tool for as-
taminated by motor and sensory deficits (Beatty & sessment (Aldridge, 1989a) (see Table 5). This would
Goodkin, 1990; Jairath & Campbell, 1990). not make music therapy a diagnostic tool. It would
Elderly patients scoring below 24 points out of a not be possible to say that patients played in a partic-
Table 3
Features Differentiating Pseudodementia From Dementia

Pseudodementia Dementia

Onset can be dated with some precision Onset can be dated only within broad limits
Symptoms of short duration before medical help is sought Symptoms can be of long duration before medical help is
sought
History of previous psychiatric dysfunction History of previous psychiatric dysfunction unusual
Patients usually complain much of cognitive loss Patients usually complain little of cognitive loss
Patients make little effort to perform even simple tasks Patients struggle to perform tasks
Behavior often incongruent with severity of cognitive Behavior usually compatible with severity of cognitive
impairment impairment
Nocturnal accentuation of dysfunction uncommon Nocturnal accentuation of dysfunction common
"Don't know" answers typical Near-miss answers frequent
Marked variability in performance on tasks of similar Consistently poor performance on tasks of similar difficulty
difficulty

After Caine (1981). Mental status changes with aging. Seminars in Neurology, I ( l ) , 39, Thieme Medical Publishers. Reprinted with
permission.

David Aldridge Collected music therapy papers 63


246 ALDRIDGE AND ALDRIDGE

Table 4
Mini-Mental State Examination

Item Component Score

Orientation for time year, season, month, date and day 5


Orientation for place state, county, city, building and floor
Registration Subject repeats "rose," "ball" and "key"
Attention for calculation Serial subtraction of 7 from 100 or spell "world" backward
Recall "Rose," "ball" and "key"
Naming Pencil and watch
Repetition No ifs, ands, or buts 1
Three stage verbal command Take a piece of paper in your right hand, fold it in half, and put it on the floor 3
Written command Close your eyes 1
Writing A spontaneous sentence 1
Construction Two interlocking pentagons
Total

Taken from Galasko, D., Klauber, M , , Hofstetter, C . , Salmon, D., Lasker, B. & Thai, L. (1990). The Mini-Mental State Examination in
the early diagnosis of Alzheimer's disease. Archives of Neurology 47 (l), 49-52.

ular way before they had the disease, or that their Music and Dementia
particular performance was a consequence of the dis-
ease, but it would provide a useful tool for assessing Late in adult life, at the age of 56, and after com-
current ability. From this platform of current ability, pleting two major concertos for the piano, Maurice
linking musical assessment to medical diagnosis, it Ravel, the composer, began to complain of increased
would be possible to recognize a broad spectrum of fatigue and lassitude. Following a traffic accident, his
therapeutic changes, including improvements or de- condition deteriorated progressively (Henson, 1988).
terioration~,which would not be confined to verbal He lost the ability to remember names, to speak spon-
abilities alone. taneously, and to write (Dalessio, 1984). Although he
Table 5
Features of Medical and Musical Assessment

Medical Elements of Assessment Musical Elements of Assessment

continuing observation of mental and functional status continuing observation of mental and functional status
testing of verbal skills, including element of speech fluency testing of musical skills; rhythm, melody, harmony,
dynamic, phrasing, articulation
cortical disorder testing; visuo-spatial skills and ability to cortical disorder testing; visuo-spatial skills and ability to
perform complex motor tasks (including grip and right left perform complex motor tasks (including grip and right left
coordination) coordination)
testing for progressive memory disintegration testing for progressive memory disintegration
motivation to complete tests, to achieve set goals and motivation to sustain playing improvised music, to achieve
persevere in set tasks musical goals and persevere in maintaining musical form
"intention" difficult to assess, but considered important "intention" a feature of improvised musical playing
concentration and attention span concentration on the improvised playing and attention to the
instruments
flexibility in task switching flexibility in musical (including instrumental) changes
mini-mental state score influenced by educational status ability to play improvised music influenced by previous
musical training
insensitive to small changes sensitive to small changes
ability to interpret surroundings ability to interpret musical context and assessment of
communication in the therapeutic relationship

David Aldridge Collected music therapy papers 64


TWO EPISTEMOLOGIES IN TREATMENT OF DEMENTIA

could understand speech, he was no longer capable of Little is known about the loss of musical and lan-
the coordination required to lead a major orchestra. guage abilities in cases of global cortical damage.
Whereas his mind, he reported, was full of musical Any discussion is necessarily limited to hypothesizing
ideas, he could not set them down (Dalessio, 1984). as there are no established baselines for musical per-
Eventually his intellectual functions and speech dete- formance in the adult population (Swartz et al.,
riorated until he could no longer recognize his own 1989). Aphasia, which is a feature of cognitive dete-
music. rioration, is a complicated phenomenon. Although
However, the responsiveness of patients with Alz- syntactical functions may remain longer, it is the lex-
heimer's disease to music is a remarkable phenome- ical and semantic functions of naming and reference
non (Swartz, Hantz, Crummer, Walton, & Frisina, that begin to fail in the early stages. Phrasing and
1989). Although language deterioration is a feature of grammatical structures remain, giving an impression
cognitive deficit, musical abilities appear to be pre- of normal speech, yet content becomes increasingly
served. This may be because the fundamentals of lan- incoherent. These progressive failings appear to be
guage itself are musical and are prior to semantic and located within the context of semantic and episodic
lexical functions in language development (Aldridge, memory loss illustrated by the inability to remember
1989a; 1989b; 1991b). a simple story when tested (Bayles, Boone, Tomoeda,
Although language processing may be dominant in Slauson & Kaszniak, 1989).
one hemisphere of the brain, music production in- Musicality and singing are rarely tested as features
volves an understanding of the interaction of both of cognitive deterioration, yet preservation of these
cerebral hemispheres (Altenmiiller, 1986; Brust, abilities in aphasics has been linked to eventual re-
1980; Gates & Bradshaw, 1977). In attempting to covery (Jacome, 1984; Morgan & Tilluckdharry,
understand the perception of music there have been a 1982), and could be significant indicators of hierar-
number of investigations into the hemispheric strate- chical changes in cognitive functioning. Jacome
gies involved. Much of the literature considering mu- (1984) found that a musically naive patient with
sical perception concentrates on the significance of transcortical mixed aphasia exhibited repetitive, spon-
hemispheric dominance. Gates and Bradshaw (1977) taneous whistling, and whistling in response to ques-
concluded that cerebral hemispheres are concerned tions. The patient often spontaneously sang without
with music perception and that no laterality differ- error in pitch, melody, rhythm and lyrics, and spent
ences are apparent. Other authors (Wagner & Han- long periods of time listening to music. Beatty (Be-
non, 1981) suggested that two processing functions atty, Zavadil & Bailly, 1988) described a woman who
develop with training where left and right hemi- had severe impairments in terms of aphasia, memory
spheres are simultaneously involved, and that musical dysfunction and apraxia yet was able to sight-read an
stimuli are capable of eliciting both right and left ear unfamiliar song and perform on the xylophone, which
superiority (Kellar & Bever, 1980). Similarly, when to her was an unconventional instrument. Like Ravel
people listen to and perform music they utilize differ- (Dalessio, 1984), and an elderly musician who could
ing hemispheric processing strategies. play from memory (Crystal, Grober, & Masur, 1989)
Evidence of the global strategy of music process- but no longer recalled the name of the composer, she
ing in the brain is found in the clinical literature. In no longer recalled the name of the music she was
two cases of aphasia (Morgan & Tilluckdharry, playing.
1982), singing was seen as a welcome release from Swartz and his colleagues (Swartz et al., 1989, p.
the helplessness of being a patient. The authors hy- 154) proposed a series of perceptual levels at which
pothesized that singing was a means to communicate musical disorders take place:
thoughts externally. Although the "newer aspect" of
' speech was lost, the older function of music was re- (a) the acoustico-psychological level, which in-
tained, possibly because music is a function distrib- cludes changes in intensity, pitch and timbre;
uted over both hemispheres. Berman (1981) sug- (b) the discriminatory level, which includes the
gested that recovery from aphasia is not a matter of discrimination of intervals and chords;
new learning by the nondominant hemisphere but a (c) the categorical level, which includes the cate-
taking over of responsibility for language by that gorical identification of rhythmic patterns and
hemisphere. The nondominant hemisphere may be a intervals;
reserve of functions in case of regional failure. (d) the configural level, which includes melody

David Aldridge Collected music therapy papers 65


248 ALDRIDGE AND ALDRIDGE

perception, the recognition of motifs and Trehub, Thorpe, & Podilupo, 1985). Temporal pre-
themes, tonal changes, identification of instru- dictability is important for tracking melody lines
ments, and rhythmic discrimination; (Jones, Kidd, & Wetzel, l98 1; Kidd, Boltz, & Jones,
(e) the level where musical form is recognized, 1984). Kidd et al. also refer to melody as having a
including complex perceptual and executive structure in time and that a regular rhythm facilitates
functions of harmonic, melodic and rhythmical the detection of a musical interval and its subsequent
transformations. integration into a cognitive representation of the serial
structure of the musical pattern. Adults identify fa-
In Alzheimer's patients it would be expected that miliar melodies on the basis of relational information
while levels (a), (h) and (c) remain unaffected, the about intervals between tones rather than the absolute
complexities of levels (d) and (e), when requiring no information of particular tones. In the recognition of
naming, may be preserved but are susceptible to unfamiliar melodies, less precise information is gath-
deterioration. ered about the tone itself. The primary concern is with
It is perhaps important to point out that these dis- successive frequency changes or melodic contour.
orders are not themselves musical; they are disorders The rhythmical context prepares the listener in ad-
of audition. Only when disorders of musical produc- vance for the onset of certain musical intervals and
tion take place can we begin to suggest that a musical therefore a structure from which to discern, or pre-
disorder is present. Improvised musical playing is in dict, change. One may not be aware of certain
a unique position to demonstrate this hypothetical link changes and become either out of tune or out of time;
between perception and production. such a loss of rhythmical structure, which appears
Rhythm is the key to the integrative process un- outwardly as confusion, may be a hidden factoiin the
derlying both musical perception and physiological understanding of Alzheimer's disease.
coherence. Barfeld's (1978) approach suggested that What is important in these descriptions of musical
when musical form as tonal shape meets the rhythm of perception is the emphasis on context where there are
breathing there is the musical experience. External different levels of attention occurring simultaneously
auditory activity is mediated by internal perceptual against a background temporal structure (Jones, Kidd,
shaping in the context of a personal rhythm. When & Wetzel, 1981; Kidd, Boltz, & Jones, 1984). Mu-
considering communication, rhythm is also funda- sical improvisation with a therapist, which empha-
mental to the organization and coordination of inter- sizes attention to the environment (Sandman, 1984;
nal processes, and externally between persons (Ald- Walker & Sandman, 1979, 1982) utilizing changes
ridge, 1989a). in tempo and volitional response (Safranek, Kosh-
Rhythm offers a frame of reference for perception land, & Raymond, 1982), without regard for lexical
(Povel, 1984). Musical tones played in sequence are content, may be an ideal medium for treatment initi-
seen as having a dual function. They are characterized atives with Alzheimer's patients. The playing of sim-
by pitch, volume, timbre and duration. They also ple rhythmic patterns and melodic phrases by the ther-
mark points in time. These tones then produce both apist, and the expectation that the patient will copy
structure in time and of time. When tones are used in those patterns or phrases, is similar to the element of
sequence only as temporal concepts they can be "registration" in the mental state examination.
thought of as providing a temporal grid, which is a Although improvised musical playing is a useful
time scale on which the tone sequences can be tool for the assessment of musical abilities, it is also
mapped for duration and location. It might profitably used within a therapeutic context. In this way, assess-
be asked what the isomorphic events in terms of phys- ment and therapy are interlinked, assessment provid-
iology are that would meet such a dual function. ing the criteria from which to identify therapeutic
There may be regular sequential pulses of metabolic, goals and develop therapeutic strategies.
cardiac, or respiratory activity within the body that
also have qualities of pitch, timbre and duration. Music Therapy With an Alzheimer's Patient
Rhythm too plays a role in the perception of mel- Nordoff-Robbins music therapy is based upon the
ody. The perceptions of speech and music are formi- improvisation of music between therapist and patient
dable tasks of pattern perception. The listener has to (Nordoff & Robbins, 1977). The music therapist
extract meaning from lengthy sequences of rapidly plays the piano, improvising with the patient who
changing elements distributed by time (Morrongiello, uses a range of instruments. his work often begins

David Aldridge Collected music therapy papers 66


TWO EPISTEMOLOGIES IN TREATMENT OF DEMENTIA 249

with an exploratory session using rhythmic instru-


ments, in particular the drum and cymbal, progressing
to the use of rhythmiclmelodic instruments such as the Example l . Rhythmic playing by the patient on a drum using a
chime bars, glockenspiel or xylophone, developing beater in her right hand.
into work with melodic instruments (including the
piano) and the voice. In this way of working, the precise, losing both its form and liveliness. The initial
emphasis is on a series of musical improvisations dur- impulse of her rhythmical playing, which was clear
ing each session, and music is the vehicle for the and precise, gradually deteriorated as she lost concen-
therapy. Each session is audiotaped, with the consent tration and ability to persevere with the task in hand.
of the patient, and later analyzed and indexed as to However, when the therapist offered an overall mu-
musical content. sical structure during the course of the improvisation,
In the case example below, music therapy is used the patient could regain her precision of rhythm. As
as one modality of a comprehensive treatment pack- suggested earlier, to sustain perception an overall
age. The patient is seen on an outpatient basis for 10 rhythmical structure is necessary, and it is this musi-
weekly sessions. Each session lasts for 40 minutes. cal gestalt (i.e., the ability to provide an overall or-
She is unable to find her way on public transport and ganizing structure of time) that fails in Alzheimer's
is brought to the hospital by her son. disease.
Frau X was a 55-year-old woman who came to the The patient reacted quickly to changes in time and
hospital for treatment. Her sister, now dead, had Alz- different rhythmic forms, and incorporated these
heimer's disease, and the family was concerned that within her playing. Significantly, she reacted fluently
she was repeating her sister's demise as her memory in her playing to changes from 414 time to 314 time,
became increasingly disturbed. She began playing the often remarking " . . . now it's a waltz. . . ." With
piano for family, friends and acquaintances at the age typical well-known rhythmical forms (e.g., the Ha-
of 40, although without any formal studies. Given this baner rhythm) in combination with characteristic me-
interest, music therapy appeared to have potential as lodic phrases, she laughed, breathed deeply, and
an intervention adjuvant to medical treatment. played with intent.
Initially the patient was referred to the hospital These rhythmical improvisations, using different
when she and her son became aware of her deterio- drums and cymbals, were played in later sessions on
rating condition, although the disease was in its early two instruments together. The patient had no diffi-
stages. At home she was experiencing difficulties in culty in controlling and maintaining her grip of the
finding clothing and other things necessary for every- beaters. Similarly, she showed no difficulty in coor-
day life. She could not cook for herself anymore and dinating parallel or alternate-handed playing on a sin-
was unable to write her own signature. When wanting gle instrument although she played mostly with a
to speak, she experienced difficulty in finding words. quick tempo (120 beats per minute). However, the
It may be assumed, given the family background, and introduction of two instruments brought a major dif-
her own understanding of her failings, that the cog- ficulty for the patient. She stood disoriented before
nitive problems were exacerbated by depression and the instruments, unable to integrate them both in the
likely to be a pseudodementia. playing. It was only with instructions and direction
from the therapist that the patient was able to coordi-
Rhythmic Playing nate right-left playing on two instruments, and
changes in the pattern of the playing were also diffi-
In all 10 sessions Frau X demonstrated her ability cult to realize (see Examples 2 and 3).
to play, without the influence of her music therapist, What did remain throughout the improvisations
a singular ordered rhythmic pattern in 414 time using was the inherent musical ability of the patient, in
two sticks on a single drum. This rhythmical pattern terms of tempo (ritardando, accelerando, rubato) and
appeared in various forms and can be portrayed as
seen in Example 1.
A feature of her rhythmical playing was that in
nearly all the sessions, during the progress of an im-
provisation, the patient would let control of the rhyth-
mic pattern slip so that it became progressively im- Example 2 . Dialogic playing on the drum.

David Aldridge Collected music therapy papers 67


ALDRIDGE AND ALDRIDGE

difficulty in playing them, which may have been com-


pounded by visuo-spatial difficulties (e.g., it is easier
to strike the surface of a drum than the limited precise
surfaces of adjacent chime bars).
Example 3. A change in the pattern of playing.
Harmonic Playing
dynamic (loud and soft), which she expressed when-
ever she had the opportunity. This would also accord At the beginning of the very first session after en-
with Swartz et al. series of perceptual levels at which tering the therapy room, Frau X set her eyes on the
musical disorders take place (i.e., levels-(a) the piano and began to play spontaneously "Happy is the
acoustico-psychological level, (b) the discriminatory Gypsy Life." She easily accompanied this song har-
level, which includes the discrimination of intervals monically with triads and thirds. The second song she
and chords, and (c) the categorical level, which in- attempted to play proved more difficult as she failed
cludes the categorical identification of rhythmic pat- to find the subdominant, whereupon she broke off
terns and intervals). from the playing and remarked ". . . that always
catches me out." This pattern of spontaneously strik-
Melodic Playing ing up a melody, and then breaking off when the
harmony failed, was to be repeated whenever she
Melody is a natural expression of motion that tried other songs like "Happy Birthday" and "Horch
arises and decays from moment to moment. In this was kommt von drauBen rein." She showed a fine
motion, the size of the intervals provides an enormous musical sensitivity for the appropriate harmony,
melodic tension that itself has a dynamic power. The which she could not always play. In the playing of the
experience of melody is itself an experience of form. drum, her musical sensitivity in her reactions to the
As a melody begins, there is the possibility to grasp a contrasting sound qualities of major and minor was
sense of the immediacy of the whole form and prepare reduced, but overall she had a pronounced perception
for the aesthetic pleasure of deviations from what is of this harmonic realm of music. As in tests of lan-
expected. This element of tension between the ex- guage functioning, the production of music is im-
pected and the unpredictable has been at the heart of paired while perceptual abilities remain.
musical composition for the last 200 years. In addi-
tion, it is melody that leads the music from the rhyth- Changes in the Musical Playing of the Patient
mical world of feeling into the cognitive world of
imagination. In the rhythmical playing on drum and cymbal, the
When Frau X played, her melodies were always therapist attempted to increase the patient's attention
lively. She knew many folk songs from earlier times span through the use of short repeated musical pat-
and was able to sing them alone. After only a few terns and changes in key, volume and tempo, hoping
notes played by the therapist on the piano, she could that the patient would maintain a stable musical form.
associate those notes with a well-known tune. How- This technique helped the patient to maintain a rhyth-
ever, when the patient tried to play a complete melody mical pattern and brought her to the stage where she
on the piano, or other melody instrument alone, it could express herself stronger musically. Above the
proved impossible. Although beginning spontane- emphasis of the basic beat in the music, the therapist
ously and fluently, she had difficulty in completing a searched for other ways to respond to and develop a
known melody. variety in rhythmical patterns by moving away from
Melody instruments, like the metallophone and the the repetitive pattern played by the patient. In a quick
xylophone, which were previously unknown to the tempo the patient was able to maintain a basic beat for
patient, remained forever strange to her. At the intro- a certain time. As soon as the tempo changed and
duction of a new melody she would often seek a mel- became slower, or the music varied with the intro-
ody known to her rather than face the insecurity of duction of a semiquaver, the stable element of the
improvisation. When the therapist sat opposite her music was disturbed and took on a superficial
and showed her which notes to play she then was able character.
to follow the therapist's finger movements. When A further change in the improvising was shown
presented with a limited range of tones, she also had when the patient recognized, and could repeat, rhyth-

David Aldridge Collected music therapy papers 68


TWO EPISTEMOLOGIES IN TREATMENT OF DEMENTIA 25 1

mica1 patterns, which were frequently realized as a production and the perseverance required for complet-
musical dialogue and brought into a musical context. ing a sequence of phrases progressively failed and
In the last session of therapy, the patient was able to was dependent on the overall musical structure of-
change her playing in this way so that she could ex- fered by the therapist.
press more strongly by bringing into line her thought-
ful and expressive playing (see Example 4). Clinical Changes
A crucial point in the music was when she chose to
play for a bar on the cymbal. Although after a while At the end of the treatment period, which also used
she trusted herself to play without help on two instru- homeopathic medicine, she was able to cook for her-
ments, she could not come to grips with a new per- self and find her own things about the house. The
sonal initiative on these instruments. This was also psychiatrist responsible for her therapeutic manage-
reflected in her continuing difficulty with what were ment reported an overall improvement in her interest
initially strange instruments, like the temple blocks. in what was going on around her, and, in particular,
She also expressed her insecurity about how to pro- that she maintained attention to visitors and conver-
ceed and needed instructions. sations. The patient regained the ability to write her
The patient displayed few changes in her dynamic name, although she could only write slowly. While
playing. She reacted to dynamic contrasts and transi- wanting to speak, she still experienced difficulty in
tions, but powerful forte playing was only achieved in finding words. The medical practitioner with overall
the last session. At times her playing had a uniform responsibility for the patient used no validated clinical
quality of attack, which gave it a mechanistic and assessment procedure for mental state examination.
immovable character. It was not possible for her to It appears that music therapy had a beneficial ef-
build a freely improvised melody from a selection of fect on the quality of life for this patient, and that
tones. It was as if she was a prisoner of the search for some of the therapeutic effect may have been brought
melodies of known fixed songs; therefore, the thera- about by handling the depression. Indeed, it may be
pist chose the free form of improvising on rhythm that the patient was suffering from a pseudodementia
instruments. confounded by her own anxiety and depression re-
garding the demise of her sister. Although the patient
Intentional Playing came to the sessions with the intention of playing
music, her ability to take initiatives was impaired.
From the first session of therapy the patient made This situation reflected the state of her home life,
quite clear her intent to sit at the piano and play what- where she wanted to look after herself, yet was unable
ever melodies she chose and to find the appropriate to take initiatives. This stimulus to take initiatives was
accompaniments. This wish, and the corresponding seen as an important feature of the music therapy by
willpower to achieve this end, was shown in all the the therapist, and appears to have a correlation in the
sessions. It was possible to use this impetus to play as way the patient began to take initiatives in her daily
a source for improvisation. In the sixth session, Frau life. Active music making also promotes interaction
X improvised a rhythmical piece in 414 time, which between the persons involved, thereby promoting in-
the therapist then transformed with a melodic phrase. itiatives in communication that the patient also en-
At the end of the phrase the patient laughed with joy joyed, particularly when she accomplished playing a
at the success of her playing and asked to play it complete improvisation.
again. The original lapses and slips in the form of the A contraindication for music therapy with patients
rhythmical playing could be carried by the intent and who are aware of their problems is that the awareness
expression with which she played. Although her over- of further cognitive abilities as experienced in the
all intention to play was preserved, her attention to playing may exacerbate any underlying depression
that playing, the concentration necessary for musical and demotivate the patient to continue.

Conclusion
If we are unsure of the normal process of cognitive
loss in aging, we are even more in the dark as to the
Example 4. Change in the form of the patient's playing. normal improvised musical playing abilities of the

David Aldridge Collected music therapy papers 69


252 ALDRIDGE AND ALDRIDGE

elderly. Any further activities will depend upon some tained. Certainly the anecdotal evidence suggests that
baseline assessment of musical improvising ability. quality of life of Alzheimer's patients is significantly
The literature suggests that musical activities are pre- improved with music therapy (Tyson, 1989), accom-
served while other cognitive functions fail. Alzheimer panied by the overall social benefits of acceptance and
patients, despite aphasia and memory loss, continue sense of belonging gained by communicating with
to sing old songs and to dance to past tunes when others (Morris, 1986). Prinsley recommended music
given the chance. However, the production of music therapy for geriatric care in that it reduces the indi-
and the improvisation of music appear to fail in the vidual prescription of tranquilizing medication, re-
same way that language fails. Unfortunately, no es- duces the use of hypnotics on the hospital ward and
tablished guidelines for the normal range of impro- helps overall rehabilitation. He recommended that
vised music playing of adults is available. music therapy be based on treatment objectives, the
Improvised music therapy appears to offer the op- social goals of interaction cooperation, psychological
portunity to supplement mental state examinations in goals of mood improvement and self-expression, in-
areas where those examinations are lacking (see Table tellectual goals of the stimulation of speech and or-
6), although such a hypothetical claim awaits further ganization of mental processes, and the physical goals
investigation. First, it is possible to ascertain the flu- of sensory stimulation and motor integration (Prins-
ency of musical production. Second, intentionality, ley, 1986).
attention to, concentration on and perseverance with In further research, single-case within-subject de-
the task in hand are important features of producing signs with Alzheimer's patients appear to be a feasible
musical improvisations and susceptible to being heard way forward to assess individual responses to musical
in the musical playing. Third, episodic memory can interventions in the clinical realm. (These can be ex-
be tested in the ability to repeat short rhythmic and tended to include multiple baselines.) Such studies
melodic phrases. The inability to build such phrases would depend upon careful clinical examinations,
may be attributed to problems with memory or to a yet mental state examinations and musical assessments.
unknown factor. This unknown factor is possibly in- Unfortunately, most of the literature concerning
volved with the organization of time structures. If cognition and musical perception is based upon audi-
rhythmic structure is an overall context for musical tion and not musical production. The production of
production and the ground structure for perception, it music, as is the production of language, is a complex
can be hypothesized that it is this overarching struc- global phenomenon as yet poorly understood. The
ture that begins to fail in Alzheimer's patients. A loss understanding of musical production may well offer a
of rhythmical context would explain why patients are clue to the ground structure of language and commu-
able to produce and persevere with rhythmic and me- nication in general. It is research in this realm of
lodic playing when offered an overall structure by the perception that is urgent not only for the understand-
therapist. Such a hypothesis would tie in with the ing of Alzheimer's patients, but in the general context
musical hierarchy proposed by S w a m (Swartz et al., of cognitive deficit and brain behavior. It may be, as
1989, p. 154) and would suggest a global failing in Berman ( 1 98 1) suggested, that the nondominant
cognition while localized lower abilities are retained. hemisphere is a reserve of functions in case of re-
However, the hierarchy of musical perceptual levels gional failure, and this functionality can be stimulated
proposed by Swartz may need to be further subdi- to delay the progression of degenerative disease. Fur-
vided into classifications of music reception and mu- thermore, it is important to point out that when the
sic production. overall rhythmic pattern failed for the patient de-
Music therapy also appears to offer a sensitive as- scribed above, the patient was able to maintain her
sessment tool. It tests those prosodic elements of beating in tempo. A similar situation may apply to
speech production that are not lexically dependent. coma patients who cannot coordinate basic life pulses
Furthermore, it can be used to assess those areas of within a rhythmic context and thereby regain con-
functioning, both receptive and productive, not cov- sciousness (Aldridge, 1991a; Aldridge, Gustorff, &
ered adequately by other test instruments (i.e., flu- Hannich, 1990). We may need to address in future
ency, perseverance in context, attention, concentra- research the coordinating role of rhythm in human
tion and intentionality). In addition, it provides a form cognition and consciousness, whether it be in persons
of therapy that may stimulate cognitive activities so who are losing cognitive abilities or in persons who
that areas subject to progressive failure are main- are attempting to gain cognitive abilities.

David Aldridge Collected music therapy papers 70


TWO EPISTEMOLOGIES IN TREATMENT OF DEMENTIA

Table 6
Comparative Elements of Two Therapeutic Epistemologies: Medicine and Music Therapy in the Treatment of Patients With
Dementia

Medical Elements of Assessment Musical Elements of Assessment Music Therapy Examples

continuing observation of mental and continuing observation of mental and improvisations using rhythmic instruments
functional status functional status (drum and cymbal) singly or in combination
improvisations using melodic instruments
singing and playing folk songs with harmonic
accompaniment
testing of verbal skills, including testing of musical skills; rhythm, melody, playing tuned percussion (metallophone,
element of speech fluency harmony, dynamic, phrasing, articulation xylophone, chime bars) demanding precise
movements
cortical disorder testing; visuospatial cortical disorder testing; visuospatial alternate playing of cymbal and drum using a
skills and ability to perform complex skills and ability to perform complex beater in each hand
motor tasks (including grip and right motor tasks (including grip and right left coordinated playing of cymbal and drum
left coordination). coordination). using a beater in each hand
coordinated playing of tuned percussion
testing for progressive memory testing for progressive memory the playing of short rhythmic and melodic
disintegration disintegration phrases within the session, and in successive

motivation to complete tests, to


achieve set goals and persevere in set
- motivation to sustain playing improvised
music, to achieve musical goals and
sessions
the playing of a rhythmic pattern deteriorates
when unaccompanied by the therapist, as
tasks persevere in maintaining musical form does the ability to complete a known melody,
although tempo remains
"intention" difficult to assess, but "intention" a feature of improvised the patient exhibits the intention to play the
considered important musical playing piano from the onset of therapy and
maintains this intent throughout the course of
treatment
concentration and attention span concentration on the improvised playing the patient loses concentration when playing,
and attention to the instruments with qualitative loss in the musical playing
and lack of precision in the beating of
rhythmical instruments
flexibility in task switching flexibility in musical (including initially the musical playing is limited to a
instrumental) changes tempo of 120 bpm and a characteristic
pattern but this is responsive to change
mini-mental state score influenced by ability to play improvised music although the patient has a musical
educational status influenced by previous musical training background this is only of help when she
perceives the musical playing, it is little
influence in the improvised playing
insensitive to small changes sensitive to small changes musical changes in tempo, dynamic, timbre
and articulation, which at first are missing,
are gradually developed
ability to interpret surroundings ability to interpret musical context and the patient develops the ability to play in a
assessment of communication in the musical dialogue with the therapist
therapeutic relationship demanding both a refined musical perception
and the ability of musical production

We had set out to negotiate a common language therapeutic changes has been developed, which is the
between practitioners, and this was achieved. Al- first step in a continuing program of research dia-
though the clinical benefits of music therapy for pa- logues. The next step is for other therapists to attempt
tients with dementia or pseudodementia remain spec- correlations with their elderly patients to see if our
ulative, a common language to discuss and compare hypotheses stand up to practical clinical investigation.

David Aldridge Collected music therapy papers 71


254 ALDRIDGE AND ALDRIDGE

Our experiences suggest that it is important to con- musical memory in Alzheimer's disease. Journal of Neurology,
sider a period of active assessment separate from ther- Neurosurgery and Psychiatry, 52 (12), 1415-1416.
Dalessio, D. (1984). Maurice Ravel and Alzheimer's disease.
apy, and that assessment must also incorporate Journal of the American Medical Association, 252 (24), 3412-
time for orientation to the music therapy setting, 3413.
the relationship, the instruments and the activity of Drachman, D., O'Donnell, B., Lew, R., & Swearer, J. (1990).
improvising. The prognosis in Alzheimer's disease. Archives of Neurology,
47, 851-856.
Eustache, F., Cox, C . , Brandt, J., Lechevalier, B., & Pons, L.
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David Aldridge Collected music therapy papers 73


International Tinnitus Journal, Vol. 11, No. 2, 163–169 (2005)

Auditive Stimulation Therapy as an Intervention


in Subacute and Chronic Tinnitus:
A Prospective Observational Study
Martin Kusatz,1 Thomas Ostermann,2 and David Aldridge3
1 Tinnitus
Therapy Center, Krefeld and Dusseldorf; 2 Department of Medical Theory and
Complementary Medicine and 2,3 Faculty of Medicine, University of Witten Herdecke, Germany

Abstract: Tinnitus is a noise, a ringing, or a roaring sound in the affected ear and is becoming
an increasingly serious problem for health care systems. Integrative treatment concepts are
currently regarded as promising therapeutic approaches for managing tinnitus. The aim of this
study was to present the results of auditive stimulation therapy, a program of music therapy
developed specifically for tinnitus treatment. We collected data on outpatient treatment results
from 155 tinnitus patients and evaluated them in a prospective observational study with three
defined times of measurement (start, end, and 6 months after the end of treatment). Apart from
anamnestic data and subjective evaluation of treatment, the major outcome parameter was the
score of the tinnitus questionnaire. To evaluate effectiveness of the therapy, we calculated ef-
fect sizes (according to Cohen). Fifty-one percent of the patients were male, and the mean pa-
tient age was 49 years. Of the 155 patients, 137 (88%) were capable of gainful employment,
which means that they fell in the age range between 18 and 65 years. The duration of tinnitus
was more than 6 months for 80% of patients, and 43% had been suffering from tinnitus for
more than 3 years. In general, all subscales of the tinnitus questionnaire showed highly signif-
icant changes (t-test, p  .01) between the measurement points “start of therapy” and “end of
therapy,” whereas no significant difference was found between the measurement points “end
of therapy” and “follow-up.” At follow-up, the values of the subscales were stabilized at a
level recorded at the end of the therapy; we did not observe a reduction to the level prior to
treatment. The values for the effect sizes mostly ranged between medium ( 0.5) and high
( 0.8). Closer investigations indicated that a combination of music therapy and psycho-
logical training rendered the best effect sizes. This study demonstrated that music therapy
is an effective integrated treatment approach and offers a way to make progress in tinnitus
treatment.
Key Words: effectiveness; music therapy; outcome research; tinnitus

T
such cases, only the person afflicted perceives the
sounds. These may occur as rustling, whistling, whir-
he term tinnitus is derived from the Latin tinnire ring, ringing, or droning sounds. High-frequency sounds
(“ringing”) and is defined as the perception of are perceived far more often than are low-frequency
sound in the absence of any appropriate exter- sounds [2], and a hearing impairment is detectable in
nal stimulation. A basic difference separates objective more than 50% of all cases.
and subjective tinnitus. The term objective tinnitus is The incidence of patients experiencing tinnitus in
used for ear sounds based on genuine physical vibra- Germany and the Western world is approximately 10%.
tions-oscillations that may be perceived by others or Some 1–2% of the population is severely disturbed by
even measured [1]. This type of tinnitus is rather rare, tinnitus, which may disrupt everyday activities and
whereas subjective tinnitus is far more frequent. In sleep [3]. If the symptoms continue for 6 months, we
consider the condition to be chronic, the degree of
Reprint requests: Prof. Dr. David Aldridge which differs considerably from person to person and

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David Aldridge Collected music therapy papers 74
International Tinnitus Journal, Vol. 11, No. 2, 2005 Kusatz et al.

affects patients in different ways [4]. A decompensated


tinnitus is accompanied in most cases by other com-
plaints (e.g., depression, anxiety, impaired sleep and
concentration, sensitivity to noises, and the like) [5–7];
consequently, intervention is required. Several treat-
ments of chronic tinnitus have been proposed and im-
plemented [8]. Among complementary therapies, home-
opathy and acupuncture are proposed [9–11]. Although
several case studies reported efficacy of these treat-
ments, the empirical support in well-controlled studies
is still weak [12,13]. Figure 1. Complete 2-week program of auditive stimulation
therapy (AST) as a function of hours of therapy per day. (A 
Today, such integrative therapy concepts as cogni- admission; PT  psychological therapy; MO  motor therapy.)
tive-behavioral treatment compiled from counseling,
relaxation therapy, music therapy, and pharmacological
preparations (lidocaine, neurotransmitters) are regarded therapy) and also included counseling by ear, nose, and
as promising therapeutic approaches for managing tin- throat experts, orthopedists, and dentists. Figure 1 shows
nitus [7]. In particular, music therapy offers the chance the complete 2-week program of AST with its different
of a global treatment approach for tinnitus patients modules.
[14]. Harmony, for instance, as a connecting link be-
tween rhythm and melody also has a social function. METHODS
Rhythm may also influence biological parameters via
tempo accentuation and meter [15]. These components At the Tinnitus Therapie Zentrum Krefeld (Germany),
form the theoretical background for auditive stimula- we performed an observational study on a multimodal
tion therapy (AST), the music therapy (MT) program treatment concept (Krefelder-Modell) being applied on
evaluated in this study. an outpatient basis for subacute and chronic tinnitus
over a projected period of 2 years. Data on treatment
THERAPY were collected and evaluated in a prospective observa-
tional study using several standardized questionnaires
AST is a complex program of MT originally employed immediately before and after therapy and at follow-up
in the treatment of chronic pain and developed specifi- after 6 months. Apart from anamnestic data, the ques-
cally for tinnitus treatment. It consists of a total of 10 tionnaires asked for a subjective evaluation of treat-
therapy sessions and employs specifically developed ment results. The tinnitus questionnaire designed by
receptive music programs in combination with an edu- Goebel and Hiller [17], now the recommended standard
cation program. Musical self-control (MSC) training is tool throughout Germany, was used at all times for
a music program designed on the basis of music psy- measurement. Included in the evaluation were only
chology and MT, the effectiveness of which was dem- those questionnaires in which more than 90% of the
onstrated in a clinical study [16]. The objective of MSC questions were answered properly.
training is to improve patients’ control of ear sounds We included a total of 155 patients in this evalua-
and to relieve their feelings of helplessness. Ringing in tion. Sufficient follow-up documentation for assess-
the ear or strange sounds bring about alterations in per- ment was available for 111 patients (71.6%). Figure 2
ception. If we encourage the ability of selective hear- shows the questionnaire instruments used and the pa-
ing, we can promote some sounds in the hierarchy of tient flow in this study.
perception and ignore other sounds or regulate them For an evaluation of the efficiency and sustained
until they become hardly perceptible. Such training im- success of the therapy, we applied the t-test to show
proves (i.e., lowers) the level of sensitivity to sounds. significant differences of tinnitus questionnaire scales
Finally, the objective of AST is to bring about a after therapy. We carried out subgroup analysis of out-
change in sound perception that induces relaxation, re- come measures according to the degree of tinnitus se-
duces anxiety, and stimulates changes in unfavorable verity. Therefore, the tinnitus questionnaire results were
behavior patterns, thus improving the emotional state. grouped in the following clinically relevant groups:
The education program is aimed at alterations on a cog- minor tinnitus (0–30 points); medium tinnitus (31–46
nitive level. points); serious tinnitus (47–59 points); and very serious
The outpatient therapy (duration, 2 weeks) with tinnitus (60–84 points).
AST consisted of a total of 38 hours of therapy (20-hr As the treatment concept presented in this study
psychological training, 10-hr MT [AST], 8-hr kinesi- (Krefelder-Modell) is a multimodal concept, the differ-

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David Aldridge Collected music therapy papers 75
Auditive Stimulation Therapy in Tinnitus International Tinnitus Journal, Vol. 11, No. 2, 2005

Figure 2. Patients and questionnaire instruments. (AST  auditive stimulation therapy.)

ent elements of treatment can be compared to achieve several possible answers. Seventy-four patients answer-
more detailed results on the efficiency of the MT train- ing this question (47.74%) reported 111 individual con-
ing program (AST). Kinesitherapy having received a sultations (main consultation with ear, nose, and throat
distinctly lower rating by patients, only the two treat- specialists), which means an average of 1.5 consulta-
ment elements rated as most successful were compared tions per patient approximately. Before treatment, pa-
with respect to their effectiveness: psychological train- tients were also asked about previous treatment; 137
ing (PT) and music therapy (MT). patients reported a total of 304 instances (i.e., an aver-
To evaluate effectiveness of the therapy and to ren- age of 2.2 treatments per patient). The major treatments
der the results comparable with each other and also were infusions (78.8%).
with other treatment facilities in the health care sector,
we calculated effect sizes according to Cohen [18] and
corrected according to McGaw and Glass [19]. RESULTS
The total score of the tinnitus questionnaire (Tinnitus
PATIENTS Fragebogen [TF]) at the different measurement points
is shown in Figure 2. The follow-up sample with regard
One hundred thirty-seven patients (88.38%) were of to the TF total score did not differ significantly from
wage-earning age (i.e., between 18 and 65 years). Table that of the general population, which has been demon-
1 shows that the duration of tinnitus was longer than strated [16]. Therefore, Figure 3 shows the mean scale
6 months for 80% of patients. A total of 43.3% had values of the tinnitus questionnaire before and after out-
been suffering from tinnitus for more than 3 years; 33.5% patient tinnitus therapy (n  146) and also at follow-up
of those interviewed reported that tinnitus developed after 6 months (n  106).
gradually. Every second patient (50.3%) said tinnitus In general, all subscales showed highly significant
set in suddenly; 16.1% did not answer this question; changes (t-test, p  .01) between the measurement
76.8% said tinnitus occurred continuously; and 21.3% points “start of therapy” and “end of therapy,” whereas
reported that tinnitus occurred with interruption. Three we found no significant difference between the mea-
patients (1.9%) had no comment. Almost all patients surement points “end of therapy” and “follow-up.” At
(94.8%) reported times at which tinnitus was particu- follow-up, the values of the subscales were stabilized at
larly intense. In contrast, only 75.5% said that at times a level recorded at the end of the therapy; we did not
tinnitus was barely perceptible. observe a reduction to the level before treatment. Ap-
Patients were also asked how often they resorted to proximately 80% of the patients with a disease severity
seeking assistance through the health care system over of medium to very serious at least moved to a clinically
6 months before treatment, and they had the option of improved stage (e.g., from very serious to serious). The

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International Tinnitus Journal, Vol. 11, No. 2, 2005 Kusatz et al.

Table 1. Sociodemographic and Anamnestic Data


Characteristic Male Female Total

Gender 51% 49% 100%


Age
Mean 48.9 yr 48.7 yr 48.8 yr
Standard deviation 12.1 yr 15.5 yr 13.9 yr
Median 52 yr 50 yr 51.5 yr
Marital status
Single 16% 17% 17%
Married or established partner 74% 64% 69%
Divorced or living separated 10% 9% 10%
Widowed — 9% 5%
Graduation
Secondary school 55% 43% 49%
Secondary modern school 25% 29% 27%
High school, A-levels 7% 18% 13%
University or college 13% 9% 11%
Profession
Laborer 33% 13% 23%
Clerk 40% 48% 44%
Self-employed 4% 3% 3%
Unemployed 24% 37% 30%
Duration of tinnitus
6 mo 20% 20% 20%
6–12 mo 16% 16% 16%
1–3 yr 20% 22% 21%
3–5 yr 14% 10% 12%
5 yr 30% 32% 31%
Loudness, ear-ringing: 0 (not at all) to 10 (maximum)
Mean (95% CI) 6.5 (6.0–7.0) 5.5 (4.9–6.1) 6.1 (5.7–6.5)
Standard deviation 2.2 2.8 2.5
Median 6 5.5 6
Disruption, ear-ringing: 0 (not at all) to 10 (maximum)
Mean (95% CI) 7.0 (6.4–7.6) 6.4 (5.7–7.1) 6.7 (6.3–7.1)
Standard deviation 2.6 3.0 2.8
Median 7 6 7
Restrictions, ear-ringing: 0 (not at all) to 10 (maximum)
Mean (95% CI) 5.8 (5.1–6.5) 4.5 (3.8–5.2) 5.2 (4.7–5.7)
Standard deviation 3.0 3.2 3.2
Median 6 4 5

details of this transition process will, however, be the


subject of a following evaluation using Marcov-chains
methods.
We determined the values of effect sizes for individ-
ual subscales and for the total score. The values for the
effect sizes were all in the range of medium ( 0.5) to
high ( 0.8), with the exception of the scale somatic
disorders, and are illustrated in Figure 4.
In a comparison of the individual therapies, AST
was responsible for a surprisingly high percentage of
the positive total result and clearly was preferred by pa-
Figure 3. Total score on the tinnitus questionnaire (TF) at the tients, despite the fact that psychological training was
different measurement points, according to degree of disease twice as long (20 therapy session hours as compared to
severity. 10 for MT). For further analysis of these findings, we

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Auditive Stimulation Therapy in Tinnitus International Tinnitus Journal, Vol. 11, No. 2, 2005

helped them to cope better with ringing in the ear, 40%


of patients described the success as excellent, 29% as
good, and 16.8% as satisfactory. At a follow-up 6 months
after the end of the therapy, the question was whether
any ear ringing was still perceivable; 3.2% of patients
reported none at all; 30.8% had a temporary absence of
ear ringing; some two-thirds of patients continued to
perceive noises during the 6 months after the therapy
ended, but these had noise that had been clearly reduced.
In summary, 52.3% indicated further positive changes
after the therapy was concluded.

Figure 4. Changes (on the tinnitus questionnaire) of scale


CONCLUSION
values in effect sizes. (E  emotional distress; C  cognitive
An analysis of the tinnitus problem, particularly from a
distress; I  intrusiveness; A  hearing problems; SI  sleep-
ing problems; SO  somatic complaints.) traditional perspective, suggests a general confusion
among most experts, although many scientists have ex-
plored the problem. A great variety of models and treat-
calculated effect sizes at measurement times and re- ment approaches are available, the effectiveness of which
lated to the patients’ subjective evaluation. Figure 5 is still inconclusive. The standard therapies in Germany
illustrates the calculation of effect sizes. include medication to improve blood circulation or,
A combination of MT and PT renders the best thera- with increasing frequency, infusions as part of a hospi-
peutic effect. MT alone ranked in second place, and PT talization period, with disproportionate side effects as
was third. The combination of MT-PT comprises the compared to the severity of the complaints [20].
partial therapies MT and PT, and this suggests that the In this study, we were able to demonstrate that the
share of MT in this result is higher than that of PT. In multimodal concept achieves highly significant changes.
addition, MT shows excellent effect sizes over longer The calculation of effect size, according to the tinnitus
periods, a clear indication of the quality of the concept questionnaire results, illustrates that the most signifi-
of AST as to contents and didactic implementation. The cant effect sizes occurred in the area of psychological
results appear to confirm in particular the intention of stress and total score changes. In comparison with ef-
enabling patients to continue independently with MT fect sizes of other studies with hospitalized patients and
and to make autonomous use of receptive music pro- outpatients summarized in a meta-analysis by Schilter
grams. The most expressive results in this context cer- [21], the advantages of this treatment concept become
tainly are those of the follow-up, as the data from these evident. With an overall effect size of 0.63 from pre-
particular patients are available for all measurement therapy to follow-up, other multimodal therapeutic
times. In retrospect, they were able to come to a conclu- strategies range far behind the results of the therapeutic
sive evaluation for themselves. approach described in this study. Medical treatments
In answer to the question of whether the therapy (e.g., tocainide, lidocaine, carbamazepine) or other rem-
edies have effect sizes in the same magnitude; however,
these therapies have side effects, such as tremor, vertigo,
giddiness, and nausea [21]. Therefore, our nonpharma-
cological intervention achieves the high effect sizes of
the drug-based therapies without their concomitant side
effects. The Krefelder-Modell treatment concept alone
uses an MT training program embedded within a com-
plex treatment approach, indicating that the advantage—
compared to other treatment forms—is principally the
influence of the specific MT intervention.
If we assume that tinnitus is not a disease but a
Figure 5. Changes in effect sizes (total, n  143; follow-up, symptom of an underlying process, singular symptom–
n  105) depending on patients’ preferred therapy. (MT  oriented approaches will fail [2]. Sixty-one percent of
subgroup of patients favoring music therapeutic elements;
MTPT  subgroup of patients who were indecisive between patients state that professional medical help was not
music therapy and psychotherapy; PT  subgroup of pa- of much use—a shockingly high figure in view of the
tients favoring psychotherapeutic elements.) numerous medical interventions. Much suggests a holistic

167
David Aldridge Collected music therapy papers 78
International Tinnitus Journal, Vol. 11, No. 2, 2005 Kusatz et al.

treatment approach, in which ringing in the ear is viewed normal and by no means pathological. Aldridge [25]
as a sign of particularly high stress. The question of suggested that the purpose of MT is that patients are en-
whether the symptom is of a somatic or a psychosomatic abled to generate expressive potentials that reveal new
nature seems to be of no importance in the treatment possibilities for becoming healthy. In the context of ear
of subacute and chronic tinnitus. An analysis not only of ringing, MT might help to create a context of meanings
the biological but of the psychological and social needs that integrates the sounds or noises into the music and
of patients [22] provides a more comprehensive insight thus removes them from conscious perception, which
into and understanding of their situation. MT AST is would clearly promote recovery. Sounds no longer per-
seen as salient to their problems among patients and as ceived as disturbing, once brought under control, are
highly effective, perhaps because we are not making a perceived as musical.
direct, singular psychological intervention but an inter- This study demonstrates that MT is an effective
vention in the same modality as that in which the symp- treatment approach and offers a way to make progress
tom is experienced. By accommodating sound control in tinnitus treatment. Music has an esthetic aspect; it is
within an ecology of other sounds, itself within a stress- part of our cultural heritage. How we integrate sounds
reduction context, we are offering a form of self-control into our daily life and how they become perceived as
that is adapted to a personal environment [23–25]. On noise or music is a complex activity involving the phys-
this extended basis of our knowledge about hearing, we iological, the psychological, and the social. A therapeu-
should be able to develop for affected patients coping tic intervention that incorporates these understandings
strategies that address the causes of the problem directly appears to offer considerable benefits, not as a cure but
and thus render the symptom superfluous. as a healthy adaptation.
Our follow-up interview of patients after 6 months
showed a high degree of sustained therapeutic success.
Furthermore, these interviews provide important feed-
back for therapists and show longer-term positive treat- REFERENCES
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amply demonstrated in our study. We hear frequently 2. Pilgramm M, Rychlik R, Lebisch H, et al. Tinnitus in der
that therapy success in most cases becomes evident Bundesrepublik. HNO Aktuell 7:261–265, 1999.
over time. If a reorientation in terms of perception takes 3. Rosanowski F, Hoppe U, Kollner V, et al. Interdiscipli-
place, the consequences of this reorientation, as thera- nary management of chronic tinnitus: II. Versicherungs-
peutic effects, are best seen in follow-up assessments. medizin 53(2):60–66, 2001.
The subjective symptom of tinnitus is a phenome- 4. Wilhelm T, Ruh S, Bock K, Lenarz T. Standardisierung
non that the unaffected cannot easily understand, as de- und Qualitätssicherung am Beispiel Tinnitus. Laryn-
gorhinootologie 74:300–306, 1995.
fining a cause is difficult in most cases. Hearing of
sounds that are normally located externally is suddenly 5. Duckro PN, Pollard CA, Bray HD, Scheiter L. Compre-
hensive behavioural management of complex tinnitus: A
directed internally and, therefore, is difficult for others case Illustration. Biofeedback Self-Reg 9(4):459–469, 1984.
to imagine. The affected individual suffers from a per-
6. Goebel G, Keeser W, Fichter M, Rief W. Neue Aspekte
sonal noise problem that is inaudible to others; conse- des komplexen chronischen Tinnitus: II. Die verlorene
quently, others lack understanding. Musicians, how- Stille: Auswirkungen und psychotherapeutische Möglich-
ever, understand this concept as part of their daily keiten beim komplexen chronischen Tinnitus. Psychother
practice [26]. “Only inner anticipatory hearing makes Psychosom Med Psychol 41:123–133, 1991.
musical interpretation possible. This phenomenon is 7. Goebel G. Studien zur Wirksamkeit psychologischer
most obvious in Ludwig van Beethoven who composed Therapien beim chronischen Tinnitus. In G Goebel (ed),
Ohrgeräusche–psychosomatische Aspekte des komplexen
without being able to hear. Accordingly, listening must
chronischen Tinnitus. München: Quintessenz, 1992:87–102.
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Neugebauer reminded us that a sensory stimulation nischen Tinnitus. Weinheim: Psychologie Verlags Union,
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explaining—taking a composer as an example—how in the treatment of tinnitus. Br J Audiol 32(4):227–233,
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served in different settings in which they are absolutely 11. Weihmayr T. Managing tinnitus with natural healing. When

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it whistles and rings in the ear. Natural Healing Series: 18. 19. McGaw B, Glass GV. Choice of metric for effect size in
Tinnitus. Fortschr Med 116(10):48–49, 1998. meta analysis. Am Educ Res J 17:325–337, 1980.
12. Biesinger E. Die Behandlung von Ohrgeräuschen. Stutt- 20. Bork K. Juchreiz nach Hydroxiethystärke: Auch bei
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13. Ernst E. Complementary and alternative medicine in the 2000.
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Neck Surg 8(3):211–216, 2000. und psychologischer Therapien bei chronischem subjek-
14. Neugebauer L. Schöpferische Musiktherapie bei Patienten tivem Tinnitus. Frankfurt: VAS-Verlag, 2000.
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15. Mosonyi D. Psychologie der Musik. Darmstadt: Tonos- 23. Aldridge D, Gustdorff D, Neugebauer L. A preliminary
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in Subacute and Chronic Tinnitus. Hanover: Proceedings of Med 3:197–205, 1995.
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Nova 10(6):260–268, 2000. Verlag Hans Huber, 1999.
18. Cohen J. Statistical Power Analysis for the Behavioral 26. Neugebauer L. Das Pfeifen nervt nicht mehr so. Musik-
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The Arts in Psychotherapy, Vol. 18, pp. 113-121. 0 Pergamon Press plc, 1991. Printed in the U.S.A. 0197-4556191 $3.00 + .00

MUSIC THERAPY AND INFLAMMATORY BOWEL DISEASE

DAVID ALDRIDGE. PhD and GUDRUN BRANDT, Dipl. MT*

This paper presents two comparative views of colitis always affects the rectum and sometimes the
inflammatory bowel disease. One is from the general entire colon.
medical literature; the other is that of a music therapist These are not generally highly fatal diseases, but
who has played extensively with patients who have they are important for public health concerns in that
the disease. The music therapist was unaware of the their incidence is early in life, therapy often involves
medical descriptions of the disease when she made surgery, there is a risk of developing intestinal cancer
her descriptions of the musical improvised playing of in later life, and there are enormous social costs
such patients. It is apparent from both sets of descrip- involved in chronic illness (Sanderson, 1986). These
tions that they have elements in common such that a ailments cause great personal embarrassment and
dialogue can occur between medical practitioners and discomfort for the patient, often resulting in a re-
arts therapists. Some implications for the treatment of stricted lifestyle and a miserable existence (Robert-
patients with inflammatory bowel disease are also son, Ray, Diamond & Edwards, 1989). Any therapeutic
discussed. endeavors must attend to enhancing the life quality of
the patient.
Inflammatory Bowel Disease
Epidemiological Factors
Inflammatory bowel disease is a term that refers to
a collection of diseases affecting the bowel. These The etiology and pathogenesis of both ulcerative
diseases are characterized by the presence of chronic colitis and Crohn's have not yet been clarified.
inflammation of the gastrointestinal tract that cannot Diagnosis is difficult. A significant time may elapse
be ascribed to any specific cause. The most common between the onset of first symptoms and a definite
of these maladies are ulcerative colitis and Crohn's diagnosis. As the diseases share similar symptoms,
disease. Both have a common insidious onset result- diagnosis is problematic (Bruce, 1986; Shivananda et
ing in chronic symptoms that may include severe al., 1987). The incidence of ulcerative colitis appears
episodic diarrhea, colicky abdominal pain, weight to be more frequent in modem Western society and is
loss, nausea and vomiting, and pus, blood or mucus increasing (Calkins & Mendeloff, 1986).
in the stool. The primary age ranges for the incidence of
Although there are common symptoms in inflam- inflammatory bowel in both sexes are between 15 to
matory bowel disease, Crohn's is distinguished from 25 years and between 55 to 60 years (Calkins &
others because it generally affects the terminal ileum Mendeloff, 1986; Shivananda et al., 1987). Children
and the right colon, sometimes the whole bowel under six years of age appear to be resistant to the
(Calkins & Mendeloff, 1986), but rarely the entire development of Crohn's; between the ages of 6 to 10
digestive tract although it can affect any part of the years ulcerative colitis, but not Crohn's, occurs with
alimentary canal (Strober & James, 1986). Ulcerative increasing frequency.

*David Aldridge is a research consultant to the medical faculty of Universitat Witten Herdecke, West Germany. Gudrun Brandt is a music
therapist.

David Aldridge Collected music therapy papers 81


1 14 ALDRIDGE AND BRANDT

There is an increased frequency of inflammatory digested. The preparation of food, the way it is eaten,
bowel in families of patients who suffer from it, with and the way that waste products are disposed of are
a mixture of both Crohn's and ulcerative colitis. This also closely patterned by culture. The offer of food
has suggested that there may be a genetic basis for the and its acceptance are also of great symbolic value
disease (Sanderson, 1986; Strober & James, 1986) (Helman, 1985; Kleinman, 1978).
although this genetic base remains as yet undiscov-
ered. Such diseases may be inherited as behaviors that Zmmunological Factors
are learned in family contexts and passed on from
generation to generation. As it has been difficult to establish an infectious
cause for inflammatory bowel disease. some research-
Diet ers have sought an immunological basis (Kett, Rog-
num & Brandzaeg, 1987; Strober & James, 1986;
Because of the nature of the malady, dietary intake Trabucchi, Mukenge, Barrati, Colombo & Fregoni,
has been considered one of the most important envi- 1986; Van Spreuuwel, Lindeman & Meijer, 1986).
ronmental exposure factors of the digestive system. Crohn's disease begins as the product of an underly-
Among patients with Crohn's, one possible causative ing inflammatory process. The presence of increased
factor is increased sugar consumption. Dietary fiber, numbers of macrophages and mast cells appears to be
increased milk products, carbohydrate, protein, and an important feature. The specific physiologic func-
total calorie consumption have also been implicated tion of mast cells remains unknown, but they are
(Persson & Hellers, 1987). known to contain inflammatory mediators, such as
The studies have proved to be problematic because histamine, and may play a role in allergic reactions.
dietary exposure may have occurred many years prior Although a pathogen has not been found, somehow
to the diagnosis, or the prolonged onset of the disease natients become sensitive to the constituents of their
may lead to the alteration of dietary practice. For own gut flora, which has widespread negative effects
example, patients may increase their consumption of on the entire immune system. Patients react nega-
refined sugar in an attempt to compensate for loss of tively to their own body, a rejection of a part of their
energy or loss of weight as a consequence of the very own self.
disease. Modem researchers have taken the old idea that
Liquid elemental diets developed for the space emotions influence the health status of people and
programs in the United States have been used for the have developed the sciences of psychoneuroimmunol-
treatment of Crohn's. Although the efficacy of such ogy - the study of the effects of psychological
a diet is not known (Sanderson, 1986), the results are factors on the immune system (Baker, 1987; Blalock
shown to be as helpful as high dose steroids for the & Smith, 1985), and of neuroimmodulation - the
remission of small bowel Crohn's in children. Chil- study of the mechanisms whereby the nervous system
dren treated in this way experience an acceleration of modulates the activity of the immune system (Baker,
growth. 1987; Stein, Keller & Schleifer, 1985; Trabucchi et
The use of nutritional supplements may have a al.. 1986). Emotions influence health status as distur-
small role to play in helping extremely sick children bances to the immune system by specific interactions
to obtain some calories, but this approach is seen as between the nervous system, immune and endocrine
beneficial only in the short term (Clark, 1986). systems. This suble combination of physiological
Patient enthusiasm for the diet wanes in the long term mechanisms is designed to recognize and deal with
because it is unpalatable. Bruce (1986) also com- nonself or altered material. What is self and nonself
mented that an elemental diet worsens the difficulties are crucial decisions isomorphic with the physiology
of young people with the disease by placing them in and psychology of the persons and the family with
a regressed position that allows the mother to exercise whom they dwell.
absolute control as she did when they were infants. Chronic stress has also been shown to alter the
What is lacking in dietary studies is a perspective immune system (Baker, 1987; Patterson, 1988; Stein
that it is not necessarilv the content of the food that is et al., 1985) and thereby recovery. Immunological
important but the way it is eaten, the situation in descriptions of inflammatory bowel disease also sug-
which it is eaten, and the conditions in which it is gest a similar process, a transient infection provoking

David Aldridge Collected music therapy papers 82


MUSIC THERAPY AND INFLAMMATORY BOWEL DISEASE 115

an immune response that is exacerbated by psycho- There appears to be a clearer link in children
logical factors. Strikingly, patients with bowel dis- between abdominal pain and emotional upset (Bruce,
ease often attribute the onset of their disease to a 1986). Abdominal pain is common in children, and
stressful event (Robertson et al., 1989). This is the gut appears to mirror the emotions better than any
literally a gut reaction to a significant life event. other body system. Furthermore, clinicians working
with children with bowel disease remark that abdom-
Psychological Factors inal pain appears to be a common occurrence in the
repertoire of distress management in the families of
There is a long history u i associating somatic those children (Bruce, 1986; Lask, 1986). There
symptoms and emotional disturbance. If inflamma- appears to be a vicious circle where the physical
tory bowel disease is, as some researchers believe, a symptoms of the disease lead to stress and behavioral
motility disorder of the gut, then that motility is problems. These problems then provoke physical
sensitive to the emotional state of the person. Highly symptoms and aggravate pre-existing organic pathol-
anxious patients may produce symptoms at times of ogy. The children and the family are affected. If the
emotional distress (Lask, 1986). family cannot cope, and there is a family repertoire of
Although psychiatric illness and psychopathology distress management by an escalation of physical
are not more prevalent in patients with inflammatory symptoms, then the symptoms of the children are
bowel disease (Clouse & Alpers, 1986), there does exacerbated further.
appear to be some evidence of depression in patients
with Crohn's (Tarter, Switala, Carra & Edwards, Lifestyle Factors and the Patient's View
1987) but this appears to occur only in those with
persistent disease activity (Robertson et al., 1989). Patients with inflammatory bowel disease have
High levels of neuroticism (a score of more than 12 on been described in the literature in a negative and
the Eysenck Personality Inventory) are associated limited way. They are seen as dependent, restricted in
with these patients and they become more introverted their relationships, sexually and emotionally inade-
as the disease progresses (Robertson et al., 1989). quate, depressed, isolated, demanding, angry, and
The search for causative psychological factors has lacking in self-confidence (Joachim & Milne, 1987).
been in vain principally because of the insidious onset A lack of self-confidence is hardly surprising given
of the disease. Although most researchers accept that that there is such a negative perception of their
psychological difficulties are sequelae of the disease patients by practitioners, combined with the difficul-
and that stress and emotional difficulties exacerbate ties of the disease itself. A number of researchers
it, no factors appear to be causative. Traditionally, have attempted to present patients' views of the
ulcerative colitis has been regarded as a psychoso- problem. As both a nurse and a sufferer, Neufeldt
matic illness. Psychoanalysis has taken the view that (1987) wrote that the most difficult part of the disease
such illness has its origins in the mental mechanisms is its unpredictability, and that the symptoms them-
used to cope with the emotions. From this perspec- selves frequently cause depression. The bouts of
tive, the disease represents a reaction to a real or nausea, vomiting, and diarrhea lead to loss of sleep,
threatened loss of the mother, or someone else on listlessness, and nutritional deficiencies. This combi-
whom the patient is dependent. Ulcerative colitis nation of embarrassing symptoms, and the random-
patients are seen as rigid, controlling, and dependent. ness of onset of those symptoms, is socially disruptive
Recent psychoanalytic approaches have observed that for the working life and home life of the patient.
inflammatory bowel disease patients have a tendency Joachim and Milne (1987) investigated the impact
to somatize their problems, and that they have diffi- of inflammatory bowel disease on the lifestyle of
culty in expressing emotions verbally (Bruce, 1986; patients. These patients said that, overall, their dis-
Stanwyck & Arnson, 1986). This state is termed ease greatly decreased their satisfaction with life. Yet,
"alexithymia." To spare themselves emotional pain, paradoxically, they reported minimal influence on a
these patients project those problems into bodily day to day basis. This appears to represent the
functioning. Hence, the situation in which some observation frequently made by clinicians that these
patients with bowel disease appear to be coping well patients appear unwilling to complain about specific
with difficult life situations. problems, or they deny that problems exist in the face

David Aldridge Collected music therapy papers 83


ALDRIDGE AND BRANDT

of evident personal and relational turmoil. a family, and the event is given meaning by the
In an attempt to understand the relationships be- patient and the family. We know that some viruses do
tween biological, psychological, and social phenom- not kill the host cell, but transform it so that it has an
ena, Helman (1985) examined the self-perceptions altered function, particularly in terms of immunocom-
and explanatory models of patients with ulcerative petence (Bloch, 1987).
colitis. He found that most patients had a multi-causal A similar situation occurs in the family context
holistic model of their disorder. Tension, anger, where a disease event is handled in a particular way
frustration, stress and uncertainty were seen as attack- (Aldridge, 1990~).Experiences surrounding gut pain
ing the body and were separate from the self. Simi- are organized around a set of beliefs about what the
larly, when their own personalities were seen as cause of the pain is, what it means, and how it is to be
contributory to the chronicity of their condition, that handled (i .e., a repertoire of distress management).
personality was seen as separate from the self. These Not only do the patient and the family of the patient
causal attributes, he argued, are learned from various share similar meanings about an illness, and what
medical encounters and are part of the culture. This counts as disease, they also share a similar immune
notion of nonself was also applied to organs of the context. In this way, a random event such as an
body. Weakness in an organ could be hereditary, infection may find that its host is not only the patient
constitutional, or acquired. Somehow the weak organ but the immunocompetence and beliefs of the family
was separate from the self, but responsive to interac- milieu.
tions with other people. The disease or organ then
becomes a public interface between the self and the Approaches to Treatment
environment and is responsive to outside forces sep-
arate from the inside self. It appears that inflammatory bowel disease is best
In Helman's view (1985), the image a person has approached from an holistic perspective that inte-
of the disease is a natural symbol whereby the grates different understandings. Although surgical
physiological process of the disease is understood: interventions will still be necessary, it is important to
remember that the sequelae of surgery are not only
. . . the symbol organizes both social and emotion- physical. Surgery can be traumatic, leaving the pa-
al experiences, and helps define certain emotions, tient with a sense of anger, resentment, feeling both
thoughts, personality traits, and parts of the body as anxious and depressed, and having to adapt to a new
either 'self or 'non-self'. Defining some of these as lifestyle. These psychological and social consequences
'non-self' can bring the patient's self image closer to may best be handled by a team approach that includes
the normative order of contemporary life - to social people who comprehend the day to day living situa-
values of independence, fitness, youthfulness, con-
tion of patients within their relational setting.
tentment and social success and control the bodily
functions and emotions. (p. 15) Lask (1986) and Bruce (1986), in their work with
children, approach their treatment from such a family
Not only does this image that persons have affect systems perspective and recommend the use of a
their physiological state, this image may also affect physician, surgeon, psychologist, social worker, nurse,
the way that they perceive, and are perceived by, and stoma therapist. Stress management techniques
members of their family (Aldridge, 1990~). can be used to reduce anxiety and communication
skills, whereas psychotherapeutic activities can be
used to control excessive worry (Freyberger, Kiins-
Family Perspective
beck, Lempa, Wellman & Avenarius, 1985; Milne et
A family systems perspective of bowel disorder al., 1986; Svedlund, Sjodin, Ottosson, & Dotevall,
emphasizes that the functions of the gut, the patient, 1983).
the family, and the treatment system evolve together A feature common to many reports about the
(Bloch, 1987; Stierlin, 1989). In this view, the treatment of inflammatory bowel disease is that it is
process of chronic illness begins by a random dis- intractable to therapeutic endeavors. Furthermore, the
equilibrating event. This could be a transient infection patients themselves are described quite negatively,
or a stressful life situation. Pain ensues. This event which may be in part because of their inability to
occurs in the context of a relationship. The patient has communicate in verbal terms about their emotional

David Aldridge Collected music therapy papers 84


MUSIC THERAPY AND INFLAMMATORY BOWEL DISEASE

distress. What is often ignored is that the communi- porated" literally means taken into the body. It may
cation medium for these patients is essentially non- also be necessary for clinicians from other disciplines
verbal. Symptoms are the forms of communication to communicate with their patients nonverbally if
that symbolize the distress of these patients. For symptomatology is the currency of communication
practitioners dependent primarily on forms of com- (Aldridge, 1990b).
munication that are predominantly verbal there is a Finally, we must attend to the symbolic aspects of
disparity between modes of communication. the disease for these patients so that they are no longer
separated from the self that feeds them. In this sense,
Implications for Music Therapy the playing of improvised music gives the disease
itself an objective appearance as a played reality.
There are no psychological factors that are neces- Patients are then offered a chance to change in the
W

sary or sufficient to cause intestinal disease in suscep- concrete sensual realm of their own existence.
tible individuals. However, it is clear that there are
certain psychological or social factors that can either
The Musical Playing of Patients With Bowel
influence the course of the disease or provide a
Disease
context for the disease to develop. The presence of
beliefs about self and nonself appear to befundamen- Our task has been to build bridges between the
W

tal in these patients, linking immunocompetence, work of medical practitioners and creative arts thera-
individual psychology, and familial status. pists (Aldridge, in press a, 1990a; Aldridge, Brandt
Although psychological factors may not be causal, & Wohler, 1990). One way to promote a dialogue
they are important for recovery. Therapeutic endeav- between practitioners is to compare differing realms
ors may be better directed to actively stimulating the of description. In the following sections we compare
immunocompetence of the patient. If the mind does the features of the improvised musical playing of
influence the immune system, there is a battery of patients with the features we find in the medical
therapeutic interventions available. As the main mode literature.
of communication about distress for patients with the Fourteen adult patients with ulcerative colitis, and
bowel disorder is nonverbal, then nonverbal therapies 12 adult patients with Crohn's disease were seen over
appear to be an esstential part of a coordinated a period of two years. The average number of weekly
therapeutic approach. sessions was seven per patient and each therapeutic
Music therapy stimulates positive emotions, en- contact lasted for half an hour. It must be ernohasized
hances coping responses, is isomorphic with the form that this research is descriptive and in the first stages
of physiological systems (Aldridge, 1989, 1990b, in of exploration. The significant factor is not the
press b) and appears to be an ideal therapeutic number of patients but the characteristics of playing
medium. The motility of the gut is rhythmic and it of those (i.e., playing with more patients
seems reasonable that music therapy could restore, or would have yielded no more characteristics) and how
promote, rhythmic flexibility. Similarly, the pro- those characteristics compare with descriptions from
cesses of the immune system too are rhythmic in their another discioline - medicine. All the sessions are
ultradian cycle. Music may provide the substrate for recorded on audiotape and later indexed.
entraining various physiological sub-systems. Essen- The method of therapy used is one of creative
tially music can "tune" the communicational context musical improvisation initiated by Nordoff and Rob-
that unites the central and peripheral nervous systems bins (1977) but adapted later at the University of
and the immune system. Witten Herdecke for working adult patients. The
It has been shown that positive experiences, such music therapist plays the piano improvising with the
as laughter when incorporated into a coping style, patient, who uses a range of instruments. This work
have a beneficial influence on the immune system often begins with an exploratory session using rhyth-
(Dillon & Baker, 1985). If this is true of laughter, we mic instruments, in particular the drum and cymbal,
may expect that the greater range of positive experi- progressing to the use of rhythmiclmelodic instru-
ences available in creatively playing music, if incor- ments such as the chime bars, glockenspiel, or
porated as a coping style, will have a healing effect xylophone, developing into work with melodic instru-
via the immune system. Note that the word "incor- ments (including the piano), and the voice. In this

David Aldridge Collected music therapy papers 85


118 ALDRIDGE AND BRANDT

way of working, the emphasis is on musical impro- patients are flexible and full of imagination. How-
visation and music as the vehicle for the therapy. ever, this has a mechanical quality as if the playing
were an intellectual exercise and never really gripped
Ulcerative Colitis the patient internally. Although able to construct and
copy melodies, there is an inability to sustain a
A prominent feature of the way these patients play melody. This gives the impression that the same
is that they appear to have no personal connection music could go on and on repetitively without any
with what they are playing. They appear to play with direction to it, and without the patients taking any
a distance from what they are playing. This distance initiatives, as if they were passive participants in an
is evident in their posture. When they are strong unrelenting process. This also appears to be a suitable
enough to stand, their posture is often such that both description for the process of chronic disease.
feet are not firmly on the ground (i.e., their legs are
crossed). The drumsticks are held loosely in the hands Crohn's Disease
with the inner wrist uppermost, and they play from These patients appear very stiff in their upper body
the wrists without involving the whole body. This movements. They too have difficulties in coordina-
seemingly uncommitted posture makes it difficult to tion and mostly alternate between left and right
play a clear beat on the drum. When the drum is handed playing on the drum.
beaten, the beats are loose. The patient allows the Rhythmic playing. Because of the coordination
beater to fall and rebound rather than make a directed difficulties, these patients' playing often sounds like a
intended beating movement. A characteristic of the gallop. Similarly the rhythmic structure is disordered
drum playing is that these patients play with alternate and gives the impression of going on and on without
hands (right, left, right, left) and they seem to have end. As with ulcerative colitis patients, there seems to
difficulty in coordinated playing using both hands be no means of initiating an end to this repetitive
together. music and consequently they appear to avoid coming
Rhythmic playing. This lack of coordination is into contact with the music. This is also reflected in
reflected in patients' rhythmic playing, which has a their inability to respond to tempo changes, giving the
limited range and often occurs as typical rhythmic musical playing a quality of immovability.
patterns: Harmony. When using specific harmonies, notably
the sixth and diminished chords, their response is one
J JJ J JJ J J7 J JY J l2 continuously; or of vulnerability. Sometimes they cry; sometimes they
J n J J J n J J J ~7 J continuously stop playing altogether, walking away from the in-
struments, or they continue to play indifferently and
This rhythmic playing does not follow the natural mechanically with even less contact to the music.
accenting, but is syncopated. Often the playing is on Melody. The melodic playing on the xylophone or
the upbeat before the bar starts, and begins with a glockenspiel is rhythmically quick, unsustained, and
small drum roll giving the music a military air. The has no internal logic. The intervals between tones are
playing itself goes on and on without any rhythmic chaotic (i.e., wide then narrow). This melodic play-
phrasing. This lack of flexibility is reflected in the ing, similar to that of the colitis patients, is generally
tempo of the musical playing where the patients quiet. There is an overall feeling of emotional dis-
constantly attempt to return to a fast tempo. tance in their playing and they give the impression
Harmony. Generally, there is an intolerance by the that they are totally at the mercy of the situation.
patient for strong harmonies in the piano playing of Overall, Crohn's and ulcerative colitis patients
the therapist and contact becomes lost, particularly have a similar lack of dynamic to their playing, which
when diminished minor, fifth, or augmented chords is limited and rigid - a feature that is reflected in the
are played. This intolerance is indicative of an emo- activity of their gut.
tional distance between the patients and the music
particularly when there is an increase in musical Process of Therapy
tension. For example, they stop playing before a
musical climax is achieved. Generally, these diseased patients require many
Melody. In the construction of melodies, these sessions before any improvement is apparent. The

David Aldridge Collected music therapy papers 86


MUSIC THERAPY AND INFLAMMATORY BOWEL DISEASE

Table 1
Comparative elements of two therapeutic epistemologies

descriptive elements from elements of the musical playing


the medical literature

0 separation of self and nonself not tuned to themselves, uncoordinated


lack of gut motility lack of rhythmic flexibility, unresponsive to tempo changes
and lack of rhythmical phrasing
increasingly introverted  quiet playing with no personal contact within the playing
restricted in their relationships difficult to contact in the musical relationship
rigid repetitive playing returning to the same tempo and
rhythmic pattern, unresponsive to tempo changes
difficulty expressing feelings intolerant of particular harmonies
 appear to be coping well with life in the face of internal appear to be going along with the music but an underlying
turmoil chaotic structure
0 dependent no initiatives within the music and dependent on the
therapist
intractable to change 0 difficult to treat requiring many sessions

coordination problems finally disappear and there is impact on life quality in the face of a disease
more stability and control of the hands. The rhythmic intractable to modem medicine.
playing becomes more definitive and there is an Furthermore, the apparent correlation between de-
apparent form to the phrasing and tempo. Overall, scriptive elements found in the literature and in the
there is less rigidity in the playing and the patients work of the music therapist, initially blind to the
appear to sense the bigger musical form in which they content of the medical literature, suggests that a
are playing. However, what remains is the impression common language between practitioners is not such a
that they never really come to grips with the music fanciful idea. A common language is achievable in
and that they still play with an empty passivity as if reality if confined initially to simple observations at
they were not tuned to their own bodies. Finally, the the level of description or usage (Aldridge et al.,
musical give and take in the therapeutic relationship is 1990). Although the two perspectives share common
difficult and they appear isolated from their musical descriptions, the creative arts have the possibility not
partner, the therapist. only for the description of pathology but to play with
what is seen as a limitation, and use it as a possibility
for change.
Conclusion
There are correlations between findings in the Recommendations for Further Research
literature that describe patients with inflammatory
bowel disease and their musical playing (see Table 1). Apart from securing a basis for clinical discussion,
Although the patients say that they have fun playing, these descriptions are the basis for futher research.
there remains an underlying intractable emotional They provide the concepts from which hypotheses can
distance within the playing and within the therapeutic be generated (Aldridge, 1988, 1990a). It should be
relationship. Any therapeutic endeavors with these possible for music therapists from other institutions
patients must take into account their personal and and backgrounds to play with patients suffering from
relational difficulties, which suggests that an early inflammatory bowel disease and discern similar char-
psychotherapeutic contact be made in the process of acteristics of playing. Similar findings, or the rejec-
treatment. This reinforces the idea of a team approach tion of what we have found, will be a significant
to chronic problems and emphasizes the value of the move in establishing a clincal validity for music
art therapies both for providing relief and for their therapy concepts.

David Aldridge Collected music therapy papers 87


120 ALDRIDGE AND BRANDT

Eisler, Szmulker and Dare (1985) found that clin- common language among the creative art therapies. The Arts in
ical descriptions were not subjective and could be Psychotherapy, 17(3), 189-195.
Baker, G.H. (1987). Invited reivew: Psychological factors and
used by family therapists of differing schools to immunity. Journal of Psychosomatic Research, 31, 1-10.
discriminate between differing family styles of behav- Blalock, J.E., & Smith, E.M. (1985). The immune system: Our
ior recorded on videotape. It should be within the mobile brain? Immunology Today, 6, 115-1 17.
compass of music therapists from other schools to Bloch, D. (1987). Family 'disease' treatment systems: A co-
evolutionary model. Family Systems Medicine, 5, 277-292.
discern whether or not there are similar characteristics Bruce, T. (1986). Emotional sequelae of chronic inflammatory
in the playing of these patients recorded on audiotape. bowel disease in children and adolescents. Clinical Gastro-
It may also be possible for other creative arts thera- enterology, 15, 89-104.
pists to find comparative elements that show similar- Calkins, B.M., & Mendeloff, A.I. (1986). Epidemiology of
ity with these descriptions. inflammatory bowel disease. Epidemiological Reviews, 8, 60-
91.
The playing characteristics of this group of patients Clark, M.L. (1986). The role of nutrition in inflammatory bowel
need to be compared with the playing characteristics disease: An overview. Gut, 72 (Sl), 72-75.
of another group of patients with a differing chronic Clouse, R.E., & Alpers, D.H. (1986). The relationship of psychi-
problem (i.e., chronic heart disease, chronic depres- atric disorder to gastrointestinal illness. Annual Review of
Medicine, 37, 283-295.
sion, osteoarthritis) to determine the characteristics Dillon, K.M., & Baker, K.H. (1985). Positive emotional states and
common to chronicity as distinct from those of the enhancement of the immune system. International Journal of
particular diseases. In addition, this work would be Psychiatry, 15, 13-17.
strengthened by establishing the musical playing char- Eisler, I., Szmulker, G., & Dare, C. (1985). Systematic observa-
acteristics of a group of healthy adults. tion and clinical insight - Are they compatible?An experiment
in recognizing family interactions. Psychological Medicine, 15,
It seems a given that psychological factors influ- 173-188.
ence the immune system. We can hypothesize that the Freybexger, H., Kunsbeck, H.J., Lempa, W., Wellmann, W., &
creative arts therapies also increase the immunocom- Avenarius, H.J. (1985). Psychotherapeutic interventions in
petence of our patients. Further cooperative research alexythmic patients with special regard to ulcerative colitis and
Crohn patients. Psychotherapeutic Psychosomatics, 44.72-81.
between clinicians and practicing therapists that dem- Helman, C. (1985). Psyche, soma and society: The social constmc-
onstrate this link will enhance the status of the tion of psychosomatic disorders. Culture, Medicine and Psy-
creative arts therapies and provide the physical evi- chiatry, 9, 1-26.
dence to support our therapeutic intuitions. The time Joachim, G., & Milne, B. (1987). Inflammatory bowel disease:
has come when music therapists and other creative Effects on lifestyle. Journal of Advanced Nursing, 12, 483-
487.
arts therapists must work together for mutual benefit. Kett, K., Rognum, T.O., & Brandzaeg, P. (1987). Mucosal
This work will enhance the service they offer their subclass distribution of immunoglobulin G-producing cells is
patients. different in ulcerative colitis and Crohn's disease of the colon.
Gastroenterology, 93, 9 19-924.
Kleinman, A. (1978). Culture, illness and care. Annals of Internal
References Medicine, 88. 251-258.
Lask, B. (1986). Psychological aspects of inflammatory bowel
Aldridge, D. (1988). The single case in clinical research. In S. disease. Wiener klinische Wochenscrift, 29, 544Ñ547
Hoskyns (Ed.), Proceedings of the Fourth Music Therapy Milne, B., Joachim, G., & Niehardt, J. (1986). A stress manage-
Research Conference (pp. 3-10). London: City University. ment programme for inflammatory bowel disease patients.
Aldridge, D. (1989). A phenomenological comparison of the Journal of Advanced Nursing, 11, 561-567.
organization of music and the self. The Arts in Psychotherapy, Neufeldt, J. (1987). Helping the IBD patient cope with the
16(2), 91-97. unpredictable. Nursing, 17, 4 7 4 9 .
Aldridge, D. (1990a). The development of a research strategy for Nordoff, P,, & Robbins, C. (1977). Creative music therapy. New
music therapists in a hospital setting. The Arts in Psychother- York: John Day.
apy, 17(3), 231-237. Patterson, J.M. (1988). Families experiencing stress. Family Sys-
Aldridge, D. (1990b). Music, communication and medicine. Jour- tems Medicine, 6, 202-237.
nal of the Royal Society of Medicine, 82, 743-746. Persson, P.G., & Hellers, G. (1987). Crohn's disease and ulcer-
Aldridge, D. (1990~).Making and taking health care decisions. ative colitis: A review of dietary studies. Scandinavian Journal
Journal of the Royal Society of Medicine, 83, 720-723. of Gastroenterology, 22, 385-389.
Aldridge, D. (in press, a). Aesthetics and the individual in the Robertson, D., Ray, J., Diamond, I., & Edwards, J. (1989).
practice of medical research: A discussion paper. Journal of the Personality profile and mood state of patients with inflamma-
Royal Society of Medicine. tory bowel disease. Gut, 30(5), 623-626.
Aldridge, D. (in press, b). Physiological change, communication Sanderson, I.R. (1986). Chronic inflammatory bowel disease.
and the playing of improvised music: Some proposals for Clinical Gastroenterology, 15, 71-87.
research. The Arts in Psychotherapy. Shivananda, S., Pena, A.S., Nap, M,, Weterman, I.T., Mayberry,
Aldridge, D., Brandt, G., & Wohler, D. (1990). Toward a J.F., Ruitenberg, E.J., & Hoedemaeker, P.J. (1987). Epide-

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miology of Crohn's disease in Regio Lieden, the Netherlands. Lancet, 2 , 589-591.


Gastroenterology, 93, 966-974. Tarter, R.E., Switala, J., Carra, J., & Edwards, K. (1987).
Stanwyck, D., & Arnson, C. (1986). Is personality related to Inflammatory bowel disease: Psychiatric status of patients
illness? Advances, 3, 4-15. before and after disease onset. International Journal of Psychi-
Stein, M,,Keller, S., & Schleifer, S. (1985). Stress and neuroim- atry, 17. 173-181.
modulation: The role of depression and neuroendocrine func- Trabucchi, E., Mukenge, S., Barrati, C., Colombo, R., & Fre-
tion. Journal of Immunology, 135, 827-833. goni, F.W. (1986). Differential diagnosis of Crohn's disease of
Stierlin, H. (1989). The psychosomatic dimension: Relational the colon from ulcerative colitis: Ultrastructure study with the
aspects. Family Systems Medicine, 7(3), 254-263. scanning electron microscope. International Journal of Tissue
Strober, W., & James, S.P. (1986). The immunologic basis of Reactions, 8, 79-84.
inflammatory bowel disease. Journal of Clinical Immunology, Van Spreuuwel, J.P., Lindeman, J., & Meijer, C.J. (1986).
6 , 415-432. Quantitative analysis of immunoglobulin-containing cells in
Svedlund, J., Sjodin, I., Ottosson, J.O., & Dotevall, G. (1983). gastrointestinal pathology. The International Academy of Ana-
Controlled study of psychotherapy in irritable bowel syndrome. lytical and Quantitative Cytology and Histology, 8, 314-320.

David Aldridge Collected music therapy papers 89


The Arts in Psychotherapy. Vol. 22, No. 3. pp. 189-205, 1995
Copyright 0 1995 Elsevier Science Ltd
Pergamon Printed in the USA. All rights reserved
0197-4556195 $9.50 + .00

A PRELIMINARY STUDY OF CREATIVE MUSIC THERAPY IN THE


TREATMENT OF CHILDREN WITH DEVELOPMENTAL DELAY

DAVID ALDRIDGE, PhD, DR. RER. MED. DAGMAR GUSTORFF and


DR. RER. MED. LUTZ NEUGEBAUER*

This paper has two main purposes. The first is an other. Research methods are simply tools for struc-
attempt to demonstrate that creative music therapy is turing our thinking and gathering the evidence that we
a viable therapeutic form for developmentally- will use to support our arguments. In some ways we
delayed children, and in doing so elucidate what it is are rehearsing a debate that has already been compre-
in the therapy that is valuable. For referring patients, hensively argued in both the fields of nursing (Dzurec
paediatricians and payers (possible funding agencies & Abraham, 1986, 1993) and social psychology
and third-party medical insurers) alike, we need to (Shadish & Fuller, 1994). By relating both sets of
present evidence that the work that we are engaged in information it may be possible to generate insights not
has a value that makes sense to them. Although we, as available from the two types of information separately
therapists and researcher, are convinced of the value (Heyink & Tymstra, 1993).
of our own work according to our criteria, we too are The overall aim of our research then is to present
seeking ways to understand how what we do is effec- our work with children suffering from a variety of
tive. The process of looking at clinical practice, developmental challenges and propose that by using a
sometimes from a different perspective, gives the pos- particular form of assessment available to other music
sibility to gain a valuable insight into what we are therapists we can see quantitatively that a beneficial
doing, to promote that work in other settings and to change occurs. The reason for that change, we will
broaden the basis of our teaching. argue, is attributable to specific qualities of creative
The second purpose is to present an integrated ap- music therapy.
proach to music therapy research that combines both The music therapy approach taken here is based
a quantitative approach, as shown by measuring upon that of Nordoff and Robbins (1977) improvised
changes, and a qualitative approach, as argued from music therapy, which has its origins in working with
the interpretation of empirical data. Although this sec- handicapped children. However, although there is a
ond purpose may seem rather unorthodox, the reason wealth of case study material in the music therapy
underlying it is that we hope to show that in music literature concerning music therapy with children and
therapy research we can creatively adapt techniques a considerable literature suggesting the value of music
and forms of argumentation to suit our needs and that therapy for child development (Wilson & Roehmann,
we do not have to take a polarized stance either for or 1987), there have been few controlled studies of Nor-
against qualitative or quantitative methods. Indeed, to doff and Robbins music therapy with handicapped
maintain an ideological position is to fall into the trap children.
of methodolatry on one hand or scientism on the An important feature of childhood development is

'David Aldridge is Professor for Clinical Research Methods at the University of Witten Herdecke, Germany.
Dagmar Gustorff and Lutz Neugebauer are CO-Directors of the Institute for Music Therapy at the University of Witten Herdecke

David Aldridge Collected music therapy papers 90


190 ALDRIDGE, GUSTORFF AND NEUGEBAUER

the acquisition of speech and the ability to communi- meaningful for them from the context within which
cate meaningfully with another person. Music therapy they find themselves. What. is selected and trans-
encourages children without language to communi- formed is in pan in accordance with their cognitive
cate and has developed a significant place in the treat- abilities, yet these abilities are not separate from other
ment of mental handicap in children. How such com- related developmental processes. Each child may dif-
munication is achieved, and how in some instances it fer in his or her development. Furthermore, children
leads to speech, are as yet unknown. Indeed, the very not only take from the environment, they too give out
ability to develop and achieve speech in normal chil- signals that modify their environment. Infants give
dren is a miracle of daily living that continues to clues to their mothers about how they expect them to
baffle linguists and psychologists. Although this pa- react. Improvised creative music therapy, with its
per makes no attempt to solve the riddle of how emphasis on activity within a dynamic personal re-
speech is brought about, we will attempt to demon- lationship, may play a role in encouraging develop-
strate how music therapy helps developmentally-chal- ment particularly when it focuses on communicative
lenged children progress toward a richer communica- abilities.
tive life. The idea that children change in regular stages that
Developmental delay can be the consequence of are governed by their biology and that they become
various difficulties, physical, mental or social (Peter- progressively better in a linear evolutionary develop-
son & Schick, 1993). Children who are developmen- ment is being challenged (Florian, 1994; Ross, Fri-
tally challenged experience the same emotional con- man & Christophersen, 1993; Spieker & Bensley,
flicts and difficulties as normal children; however, 1994; Wagner, Torgesen & Rashotte, 1994). Morss
they are also more likely to experience rejection when (1992) called for an interpretative, as opposed to a
they fail to meet standards of expectation associated causal-explanatory, approach to human experience
with their chronological age. This rejection can lead and proposed that studies of infancy are often studies
to behavioral disturbances. The successful social in- of scientists studying infancy, and, like Sipiora
tegration of children with developmental delay relies (1993), found that the infant under study is often ab-
upon a sensitive and adaptable social environment, as sent. Sipiora criticized Piaget for skewing the natural
does the sequence of development itself. If the envi- choice of questions answerable only by children to
ronment is both modified to meet the needs of the those of an adult consciousness. Pure observation
children and to enhance communication possibilities cannot always distinguish children from their beliefs
according to their potential, then we may expect and it is the inner life of the children, what they wish
fewer behavioral problems. Children who are devel- to communicate, that should be the focus of our at-
opmentally delayed face the same developmental tention (Florian, 1994; Wagner, Torgesen & Rash-
tasks and challenges and have the same needs to be otte, 1994). Siege1 (1993) reminded us that this de-
loved, stimulated and educated, as normal children. bate is not entirely new and, interestingly for the cre-
What they face is a progression that may be slower ative arts therapies, that nonverbal tasks are the best
and perhaps limits their future capabilities. Our ther- means of representing the thinking of very young chil-
apeutic task is to respond to abilities and potentials so dren. She also emphasized that Piagetian develop-
that those limitations themselves are minimized. If mental stages are not supported empirically and what
both environment and the individual are important for may seem to be an orderly sequence of acquisition
developmental change, the therapist provides, albeit may indeed be an artefact of the way in which tasks
temporarily, an environment in which individual are structured. The outcome of this debate is that in
change can occur. understanding children we are encouraged to study
processes not products, that those processes when re-
Child Development and Challenges to Theory lated to assessment will always occur in a dialogue
between child and therapist.
Child development itself is subject to various theo- If we return briefly to the secondary purpose of this
ries and is a continuing source of active academic paper, we can propose that a qualitative method of
debate. All children are now conceived of as very research will be necessary to look at this process of
active constructive thinkers and learners, rather than developmental change as it occurs between therapist
passive copiers of what is given to them (Case, 1993; and child, and a quantitative method can help us to
Lewis, 1993). Children select and transform what is identify specific changes

David Aldridge Collected music therapy papers 91


CHILDREN WITH DEVELOPMENTAL DELAY 191

The above challenge to Piagetian orthodoxy is its own time, yet the process of socialization and the
based partly on a questioning of the orthodoxy of the use of language depend upon entraining those
spoken word as being primary (Siegel, 1993). Some rhythms with those of another. Cycles of rhythmic
authors are concentrating on how children perform in interaction between infants and mothers reflect an in-
the world, which is a "world-of-others," as the prin- creasing ability by the infant to organize cognitive and
cipal focus for attention. Play is seen as a mental act affective experience within the rhythmic structure
including unconscious fantasies and wishes, a physi- provided by the parent. This organization, however,
cal act that is observable and a necessary awareness is not a one-sided phenomenon. Infants produce
that what is being enacted is "play." Play, when forms of expression and gesture that are not imita-
defined by its functions, facilitates the libidinization tions of maternal behavior. Both baby and mother
of the body and is an area of importance bridging the learn each other's rhythmic structure and modify their
realms of the personal and the social (Mash, 1993). own behavior to fit that structure. Arousal, affect
For Vygotsky (1978), this intermediary realm, the and attention are learned within the rhythm of a
distance between what children can do on their own relationship.
and what they can do with the help of an adult, is The competence of infants is not solely a quality
referred to as the proximal zone. It is such a "zone" inherent within the individual. Individuals are located
that we find in creative music therapy. Musical activ- in particular environments, those of their significant
ity is based upon what the child can do in musical relationships. Gaussen (1985) criticized maturational
play, but the potential of what the child can do further models of child assessment in that they do not take
is based upon what child and therapist are capable of into account the variability and individual differences
together. Furthermore, with an emphasis on the ac- of the developmental processes. Assessment methods
tivity of musical playing within the context of a per- rely on how the child responds and moves; they tell
sonal relationship, the libidinization of the body is little about what the child knows and responds to.
achieved as a communicative act. Such a criticism echoes that of the authors above who
In our work we emphasize the role of the therapist wish to know more of the inner life of the child, a
as encouraging and providing the context in which life that is not solely dependent upon intact motor
musical communication takes place. The therapeutic responses.
relationship is a relationship that mirrors the primary Nevertheless, communication is dependent upon
relationship of learning to communicate in which de- motor coordination, and motor responses, as we shall
velopment emerges. Vandenberg (199 l ) reminded us read below, are important indicators that a child is
that looking, hearing, smelling, sucking and grasping developing. For the parent, rather than the theoreti-
are some of the early reflexes for assimilating objects cian and psychologist, the pragmatics of understand-
and the basis from which cognitive development ing the child are based upon what that child can do.
emerges. At birth, children are most responsive to the Furthermore, communication is also dependent upon
human voice through hearing. It is this orientation to doing. What that "doing" means is important, but
the social world of others that is of such importance. achieving that "doing" and coordinating with another
The special relationship with others is something that person are primary. Hence the value of nonverbal
is "elaborated from those primitive forms of attune- therapies and the establishment of a communicative
ment" (p. 1282). This is a reflection of the position relationship before the complexities of lexical mean-
taken by Stem (Neef, 1993) that the infant has a core ing are necessary.
self that is in a relationship with the core self of the
other, and this relationship forms a crucial axis of Motor Development: Gesture and Communication
development. The symbolic world of the child is im-
bued with the relationship with the caregiver and oth- The development of children demands many inte-
ers of significance. Our proposal is that such a rela- grated skills. One important skill is to control motor
tionship is essentially "musical. " activity, that is, to be able to draw and write, handle
Aldridge (1989) has emphasized the importance of a knife and fork, play with a ball and run. Children
rhythmic interaction for the development of language who do not master such activities are often labelled as
and socialization in the infant. From birth the infant clumsy, whereupon they meet with disapproval from
has the genetic basis of an individually entrained their peers and often family members. On reaching
physiology (i.e., a self-synchronicity). The infant has play-school or school age these children find them-

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192 ALDRIDGE, GUSTORFF AND NEUGEBAUER

selves facing ridicule. Such ridicule may then lead to children at their stage of understanding in that gesture
a lack of self-esteem and confidence, which is further maps the phenomena closely. Indeed gestures in a
exacerbated by social withdrawal (Winemiller & communication dialogue are preverbal and do not
Mitchell, 1994). Once such children find they cannot need the extra abstract and lexical dimension of
perform "properly" they give up trying. The conse- speech. It is such gestural activities that are actively
quences of such personal and social handicap as clum- utilized in the repertoire of play songs used in the
siness or perceptual-motor dysfunction remain into Nordoff and Robbins approach.
adult life. Active music therapy then would seem to be a
There are three main processes assumed to be nec- relevant therapy form as it concentrates on, and fos-
essary for the performance of motor skills: kinesthe- ters, the use of purposive coordinated movements that
sis, muscle control and timing (Laszlo & Sainsbury, occur in a context of time and relationship, offering a
1993). Kinesthesis is the sense that conveys informa- form for communication without words.
tion about the position and movement of the body and
limbs. This sixth sense, referred to by Sacks as
Developing Children and Music Therapy
"proprioception," is a sense we have in our bodies
and is Twelve patients were assessed, selected and ran-
domly allocated into two groups of six children (see
that continuous but unconscious sensory flow Figure 1). Each child was to receive individual music
from the movable parts of our body (muscles, therapy. This formed a treatment group and an initial
tendon, joints), by which their position and tone non-treatment group to serve as a waiting-list control.
and motion is continually monitored and ad- The non-treatment group received music therapy after
justed, but in a way which is hidden from us waiting for three months, while the previously treated
because it is automatic and unconscious. children had a break from therapy. Our intention was
(Sacks, 1986, p. 42) to stay as close to the clinical practice of music ther-
apy as possible. This intention influenced the timing
Proprioception is indispensable for our sense of of the treatment stages in that a course of music ther-
self in that we experience our bodies as our own. apy treatment takes about three months followed by a
Muscle control refers to the way in which movement three-month pause. Similarly, we could only ever
is directed and controlled spatially. These movements take on six new patients in one treatment period. All
must also be coordinated and this involves timing. the subjects of this study would receive music ther-
Laszlo (Laszlo & Sainbury, 1993), however, argued
that kinesthesis is the overarching factor that unites
both direction and timing in the control of posture, in
error detection and in memorizing movements. In-
deed, the coordinating of action involves the whole
body and, von Hofsten (1993) asserted, can only be
understood as a purposive dynamic future-oriented
interaction between the organism and the external
world. Actions originate not from reflexes, but from
spontaneously produced, purposeful controlled move-
ments (i.e., actions develop through action). Yet this
action must be structured and thisstructure is that of
time. Active music therapy would seem to be an ideal
medium for encouraging purposeful controlled move-
ment in a time structure that is formed yet flexible.
Gestures also help us understand what a child
means and at what stage of understanding a child is in
(Alibali & Goldin-Meadow , 1993; Goldin-Meadow ,
Alibali & Church, 1993). Gesture is spontaneous and
often idiosyncratic, whereas speech conforms to an
established form. Some expressive events may be bet- Figure I . Allocation of children to treatment groups and study
ter encoded in communications as gestures for some design.

David Aldridge Collected music therapy papers 93


CHILDREN WITH DEVELOPMENTAL DELAY 193

apy, and the maximum treatment delay after intake these observations she developed a series of scales
would be for three months. that could be used to gain insight into areas of leam-
Entrance criteria were that the children should be ing in young children. The function of these scales
4-6.5 years in chronological age with a developmen- was not to say categorically what the reason may be
tal age of 1S-3.5 years and that the selected children for a child's slowness to learn, rather to diagnose
had no previous experience of music therapy. Chil- those areas of a child's capability and to provide a
dren were excluded from the study if they had a phys- profile of capabilities from which the child may re-
ical problem that was degenerative, if they were cur- spond to treatment. This emphasis on the positive
rently receiving psychopharmaceutical treatment or if potential of the scales was attractive initially for our
they were currently attending another form of creative work as it reflected, and had features complementary
art therapy. Playschool or kindergarten attendance with, the approach of Nordoff and Robbins music
was not interrupted. therapy (see Table 1) in focusing on the inherent po-
The use of waiting list controls and alternating tential~of the child rather than concentrating on the
treatment periods met our ethical demands for the known pathologies. Reading her book (Griffiths,
treatment of children in terms of clinical research in 1954), which was written 4 0 years ago, is a fascinat-
that both procedures mirrored our normal practice. ing insight into the rigor of a scientist who clearly has
Furthermore, the study was clearly explained to all a love for children, and how that rigor can be applied
the participating parents and caregivers of the chil- in the assessment of behavior. Sometimes creative
dren, who were assured that refusal to take part in the arts therapists criticize science for seemingly leaving
study would not disqualify their childrenfor treat- out the individual and thereby losing any relevance
ment. Similarly, all participants were asked to give for treatment. With Griffiths, however, there is a con-
permission for the use of the data as part of a research stant reminder that these scales were crafted from a
project and for possible publication. devotion to the lot of those children who were in need
Referrals were from a local paediatrician who as- so that we, as carers of those children, could better
sessed the children before treatment began (at intake). our own observations to meet their needs.
We had previously set the criteria for the clinical as- There are six subscales that have equal degrees of
sessment of developmental change (see below). A difficulty. Each subscale tests a different avenue of
medical student, trained in the assessment of children, learning with the intention of discovering true poten-
saw the children and their caregivers every three tialities in the handicapped child (Griffiths, 19701
months to assess any clinical changes according to the 1984, pp. 171-172). Once such potentials are recog-
medical criteria (Tests 1 , 2 , 3 , and 4 after intake). She nized, help can be brought as early as possible when
was initially "blind" as to whether the children were needed. Indeed, the tests are intended to educate the
in the treatment or non-treatment group. carers and the educators about the needs of the child.
The main assessments were developmental accord- Although the central plank of the work is to provide a
ing to psychological and functional criteria (the Grif- differential diagnosis of mental status (see Figure 2),
fith's test, see below), and musical according to the that diagnosis is clearly linked with potentials for
Nordoff and Robbins rating scales. Music therapy treatment.
sessions were recorded on audiotape and later indexed Attempts were made by Nordoff and Robbins as
according to music therapy criteria. early as 1964 to develop rating scales for individual
Our main hypothesis was that there would be music therapy (Weaver & Clum, 1993). However,
greater developmental changes in the music therapy these evaluative scales proved to be difficult to com-
treatment group, in the first session of the treatment pose and adequately meet the complexity of musical
period, compared with the no-treatment group. Our responses. Two years later, scales for evaluating au-
secondary hypothesis was that by the end of the two tistic children in the day center were adapted for
treatment sessions both groups would have changed music therapy use and evolved as Scale 1. Child-
equally. Therapists Relationship in Musical Activity and Scale
11. Musical Communicativeness.
The Griffiths Scale and the Nordoff and Robbins Scale I evaluates the relationship between child
Rating Scale F ,
and therapist as it develops from what may be total
obliviousness, through limited response to a stability
Ruth Griffiths, as a psychologist, spent a great deal and confidence in the mutuality of playing music to-
of time observing babies and small children. From gether. It must be stressed that it is in the musical

David Aldridge Collected music therapy papers 94


ALDRIDGE, GUSTORFF AND NEUGEBAUER

Table l
A comparison of contents of the Griffiths Scales and the Nordoff and Robbins Rating Scales

Griffiths' Subscales Nordoff and Robbins Rating Scales

A: Locomotor Development Scale 11: Musical Communicativeness


pushes with feet, lifts head, kicks vigorously, begins to musical communication is realized through 3 modes of activity;
crawl, climbs, can walk on tiptoe, catches a ball. hops and instrumental, vocal and bodily movement.
skips.
B: Personal-Social Scale Scale I: Child Therapists Relationship in Musical Activity
responds to being held, smiles, resists adult taking a toy Item 1-3. Child appears oblivious to the therapists, fleeting signs of
away, anticipatory movements, plays "pat-a-cake," plays awareness, awareness of the situation leads to rejection.
with other children, has a special friend. Item 6: Child comes to the session with obvious pleasure and
establishes a consistently recurring positive response to the therapy
situation.
C: Hearing and Speech Scales I and 11: Musical Communicativenesst
most intellectual of the scales, indicative of hearing Ranges from uncommunicative, non-responsive beating which is
problems; startled by sounds, vocalization other than disordered, impulsive or haphazard or compulsive beating of
crying, searches for sound visually, listens to music*, inflexible tempo or pattern**; leading to child beats with some
listens to conversations. rings bell, likes rhymes and musical organization, and recognizes salient components of the
jingles, enjoys s t o r y - b k , develops words and speech, music, rhythm or melody or harmony. Child finds musical activity
names objects, defines by use, comprehends sentences. meaningful and satisfying.
Child communicates with others and communicates his understanding
of musical objectives.
The child comes to the session with obvious satisfaction and pleasure,
and enjoys being active in the music.
D: Hand and Eye Co-ordination Scale 11: Musical Communicativeness
(observe the hands of the child) Musical communication is realized through 3 modes of activity;
follows visually moving objects, uses hands for instmmental, vocal and bodily movement.
exploration, points with fingers, likes holding toys, plays
with bricks, scribbles freely, builds a tower, folds paper,
copies shapes, draws recognizable figures and objects.
E: Performance Tests Scale 11: Musical Communicativeness
measures skill in manipulation, speed of working and His beating shows an awakening recognition and some anticipation of
precision with an awareness of the child's eagerness and salient components of the music; rhythmic pattern, melodic rhythm,
persistence; searches for a toy under a cup, manipulates change of dynamics, phrase structure.
cubes and boxes, opens screw-topped jars, makes
patterns.***
F: Practical Reasoning Scales I and 11: Musical Communicativeness~
recognition of differences in size and categorizing as He adopts and sustains the mode(s) of musical response available to
"bigger," this scale measures the ability to reason in him, shows purposeful involvement with the musical activity. The
"embryo." Any child before he or she can express ideas child's interest centers strongly upon particular musical activities
verbally can look, listen, think and learn the foundations which he finds meaningful and satisfying. He pursues these activities
of knowledge and the way in which the mind works in with purposefulness.
apprehension of the environment.

*There is an overall neglect of musical ability.


**Moves from pathology to ability, yet lacks the neutrality of the Griffiths' scales which assess all stages as milestoneslpotentials
***There is, however, no mention of musical patterns.
tAfter Item 6 the Nordoff and Robbins scales converge.

activity that the relationship is developed, and the ing the child (i.e., we would not expect that the ther-
vocabulary used to evaluate the performance of the apist is totally oblivious of the child).
child is mainly musical. Whereas Nordoff and Rob- Scale I1 attempts to evaluate both the state of mu-
bins stress that the evaluation is of the relationship sical communication in the session and, "provides an
itself, the language itself places emphasis on evaluat- index to the personality development of a child

David Aldridge Collected music therapy papers 95


CHILDREN WITH DEVELOPMENTAL DELAY

ievereiy retarded childv Severe hearing loss ' M n ' s syndrome Slow child Average ability chi!d

A = locomolor development D = hand and eye cocxdination


B = personal-social relationship E = performance tests
C = hearing and speech F = practical reasoning

Figure 2. Examples of Griffith's profiles for varying groups of children.

through assessing the character and consistency of the possible to continue the full program of treatment and
musical communicativeness he manifests'' (Nordoff assessment. Two children came from families of eth-
& Robbins, 1977, p. 193). The scale includes three nic minorities and it was both difficult to get them to
modes of activity-instmmental, vocal and body music therapy sessions and to maintain the continuity
movement, which provide an aggregate rating on l 0 of follow-up.
levels of communication ranging from "no commu- By the end of the study there were two unbalanced
nicative response" through active participation to an groups, similar in chronological age, but different in
intelligent musical commitment. Both scales are mental age despite the random allocation. We see in
rather rough and ready and have never really been Figure 3, which illustrates the Griffiths subscale
validated in clinical practice. Indeed, after level 6, scores for the children in both groups, in comparison
both scales converge and could be conceivably col- with Figure 2, that the children range from what is
lapsed into one scale. However, the scales do provide considered to be severely delayed to the "slow"
an available clinical guide to practice and evaluation. child. Five, out of the eight children, failed to score
on the practical reasoning scale (Subscale F). Sub-
Results scale F is heavily dependent upon speech and repre-
sents the general language deficits in these children.
A clinical trial, even with limited numbers, is an However, we see by the final assessment sessions,
exercise in good will, good planning and good for- Figure 4, that all the children have developed some
tune. Although planning to treat 12 children, we capacity for practical reasoning. Indeed all the chil-
"lost" 4 children in the study, lost in the sense that 4 dren improve, as would be expected. Children de-
children could not be included in the end results for a velop with or without music therapy. But the rate at
variety of reasons. One boy during the first sessions which they develop and how this is possibly influ-
of music therapy was discovered to be profoundly enced by music therapy is the subject of this study.
deaf rather than being mentally handicapped and de- We see in Figure 5 that the changes in the Griffiths
velopmentally delayed, which meant that he had to be scores do indeed differ according to which group the
fitted with hearing aids. T h i ~
finding seems to point to children are in. During the same period of time from
music therapy assessment as a valuable diagnostic intake, the first treatment group (A) changes more
method for developmenta!ly delayed children simply than the children who are on the waiting list (mea-
because it brings attention to active hearing in an sured at Test l). When the waiting list group is treated
almost naturalized setting. One other child had been and then tested (at Test 21, and the children who were
abused by a member of her family and it was not treated take a rest, the newly treated children start to

David Aldridge Collected music therapy papers 96


Group A
im

lm

80

E 60
6
m
L

g
CJ
40

20

0
Kathlean David Sophie Zena ' Tomrny

Group B
7
lrn A B C D E F

l A B C D E F

Salty Suzie

A = locomotor development D = hand and eye coardination


B = personal-social relationship E = performance tests
C = hearing and s p c h F = practical reasoning

NOW lhal four of lhe children in Gmup A. and one chiid in Gmup B, do not score on the practical reasonong scale

Figure 3 . Griffiths Quotient intake profiles.

catch up in their development. Such differences can the individual subscale changes of the Griffiths scale.
be demonstrated at a level of statistical significance When we look at the subscale changes (see Table
(at Test l df = l , F = 7.072, P = 0,045) and 21, there are significant differences between the
support our initial hypotheses that music therapy will groups. First, there is a continuing significant differ-
bring about an initial change. Although it appears ence on the hearing and speech subscale and the sta-
clear that music therapy does make a difference to the tistic points to a significantly changing ability to list&
development of these children, it does not immedi- and communicate. The personal-social interaction
ately tell us why music therapy helps or what indeed is subscale (B) also proves to be the significant differ-
changing specifically. It makes sense here to look at entiator at Tests l and Tests 3. After Test 3, the

David Aldridge Collected music therapy papers 97


CHILDREN WITH DEVELOPMENTAL DELAY

Group A

'T----

Kathleen David Sophie Zena Tornrny

A = locomotor development D = hand and eye coardination


B = personal-social relationsh~p E = pcrfomance tests
C = hearing and speech F = practical reasoning

Figure 4 . Griffiths Quotient final assessment profiles.

children in Group A have received two treatment pe- Although focused listening in a personal-social re-
riods of music therapy. It must be noted here that lationship sets the scene for music therapy and pro-
Tests 2, 3 and 4 are all made after children have been vides the context in which change can occur, a further
treated at least once with music therapy. Music ther- investigation of the data reveals an important variable
apy seems to have an effect on personal relationship, related to hand-eye coordination that is correlated
emphasizing the positive benefits of active listening with significant clinical changes when the children are
and performing, and this in turn sets the context for tested. Subscale D, which measures hand and eye
developmental change. Howevtx, the groups also dif- coordination and is taken to be demonstrative of non-
fer initially on hand-eye coordination (subscale D), verbal communication (Muenzenmaier, Meyer & Fer-
and this is not surprising given that the playing of ber, 19931, is significantly correlated with change
musical instruments demands such manipulative and throughout the series of test times. At Test l (Pearson
perceptive skill. r 0.915, Bonfen-oni p 0.001) and Test 2 (Pearson r

David Aldridge Collected music therapy papers 98


ALDRIDGE, GUSTORFF AND NEUGEBAUER

Q
no music therapy

A
with music therapy

no music therapy

no music therapy

with music therapy

with music therapy

no music therapy

- l
Group A Group B

n e s e changes are lhe mean changes from when the children were measured at inlake; lhaf
is, lhe inlake is the baseline, zero. The test scores, l ,2,3 and 4 are the mean changes in the
Griffilhs quotienls for each group at three months, six months, nine monlhs and one year
fouowing the inital measurement at intake. Note at test 4 in Group B lhere appears to he a
regression in the changes.

Figure 5. Group differences in Griffiths test score means changes from intake.

0.903, Bonferroni p 0.002), hand-eye coordination is dination and listening, appears to play a significant
correlated with the hearing and speech scale change, role in developmental changes.
scale C. A change occurs on both scales of nonverbal
communication and potential verbal communication. Case Vignettes
Furthermore, at Test 3, hand-eye coordination is cor- Although it may be unorthodox to include clinical
related with changes in the performance tests, scale E case studies alongside statistical reasoning, we be-
(Pearson r 0.902, Bonferroni p 0.033), and later at lieve that a time has come when we can have the
Test 4, hand-eye coordination is correlated with freedom to add some variety to the way in which our
changes in practical reasoning (Pearson r 0.933, Bon- work is presented. There are no statutes that say case
ferroni p 0.010). The active element of musical play- vignettes are banned from such work and, as most of
ing, which demands the skills of hand and eye coor- us know from reading the work of other clinicians,

David Aldridge Collected music therapy papers 99


CHILDREN WITH DEVELOPMENTAL DELAY

Table 2
Effect of treatment group on subscale scores

Subscale Test time SS DF MS F P

A: locomotor development Test l


error
Test 2
error
Test 3
error
Test 4
error
B: personal-social Test 1
error
Test 2
error
Test 3
error
Test 4
error
C: hearing and speech Test l
error
Test 2
error
Test 3
error
Test 4
error
D: hand-eye co-ordination Test l
error
Test 2
error
Test 3
error
Test 4
error
E: performance tests Test 1
error
Test 2
error
Test 3
error
Test 4
error
F: practical reasoning Test 1
error
Test 2
error
Test 3
error
l Test 4

error

Univariate F tests: *significant p < 0.05; **significant p < 0.01

David Aldridge Collected music therapy papers 100


ALDRIDGE, GUSTORFF AND NEUGEBAUER

what we often really need to know is how the statis- At first Dora told her adoptive mother that she
tical relevance comes to have any clinical relevance. would not come to music therapy, but, after the first
In these two examples we see that although clear de- few sessions, appeared to come gladly. At home she
velopmental changes accessible to assessment take displayed both sympathy for others and sadness. That
place, it is the qualitative subtleties of personal mean- she herself could be emotional was an important ex-
ing that play an important role for the parents. In perience for her mother. Similarly, Dora made it clear
the first study, a clear quantitative change takes she was happy to see her mother and said that she
place in the Griffiths test score (see Figure 7). In the loved her. Although previously distant, she now cud-
second example, although no clear objective change dled others and was happy to be cuddled. After two
occurs in the test scores over time (see Figure 6), the music therapy sessions Dora began to sleep well, and
parents see important qualitative changes that they sleep alone, which was a great benefit for the parents.
perceive as improvements. When she had an episode of agitation she said that she
no longer needed to be held and could manage alone.
Dora Instead of using single words, she combined words
together as phrases and could say "I," "we" and
Dora, the child of a mentally handicapped mother "you" in the proper context.
and a socially disturbed father, was adopted at birth. After the second treatment block, she became dry
While experiencing feeding difficulties she put on during the day. The table in her bedroom, once used
weight. She was developmentally delayed, hyperac- for changing her diapers, became a desk. Although
tive and often uncontrollable. As a baby she received not being particularly comfortable at the kindergarten,
physiotherapy because she started to walk late and, at she started to make friends.
the time therapy began, was still in diapers. Her major
problem was presented as episodes of agitation and Sophie
restlessness after which she appeared to have lost
much of what she had previously learned. Following Sophie was a much wanted child, as her mother
such episodes she said that she would fall or her head had previously miscarried twice. Although being able
would fall off. An electroencephalogram showed no to sit alone at four months, she failed to crawl and
obvious signs of pathology. Socially she was distant failed to pull herself up to stand. There appeared to be
from other children and adults, was extremely anx- no organic cause for such delay. The physiotherapist
ious in the presence of others and protected her eyes found that Sophie had difficulties with both her fine
with her arms clamped to the sides of her head. She and coarse motor control. Although able to hear nor-
would not listen to others or make eye contact. Some- mally, she failed to speak. Sophie also played alone
times her voice had a strange "fairy-tale" character. and was not interested in distractions. After a virus
She had been seen by a child psychiatrist. infection and a fever of up to 42 degrees centigrade
At the beginning of the music therapy Dora cried a when she was unconscious for a short time, she be-
lot and had t o be held in the arms of the CO-therapist came very anxious. An electroencephalogram showed
throughout the session. When he tried to put her down no obvious signs of irregularity.
she cried even louder. Eventually she responded to In the first session Sophie clung to her mother and
the musical structure offered to her and, although was carried into the therapy room by the CO-therapist,
making no eye contact with the therapist at the piano, on whose arm she remained. Her hands shook, she
rang a small bell with her finger. Gaining in confi- whimpered and was very anxious. She played a small
dence, while remaining in the arms of the co- bell and a chime bar so quietly that they could hardly
therapist, she played the cymbal continuously. When be heard.
asked if she had finished playing, she replied clearly In the second session she was also very withdrawn
that she had. Eventually, in the fourth session, she and came crying into the room. However, with the
had confidence to play a drum alone. Now there was support of the CO-therapistshe played single tones on
no crying and she looked confidently at the therapist. the piano, sat on the CO-therapist's lap and played
The therapist had composed a special "Good-bye separately both drum and cymbal.
song" for her and she sang, too! By the tenth session, By the fourth session she was able to come into the
her musical playing was formed and she played a therapy room alone and, after a while, came to the
crescendo alone. piano where she played single unrelated tones, which

David Aldridge Collected music therapy papers 101


CHILDREN WITH DEVELOPMENTAL DELAY 20 1

at times accidentally met the music played for her by drum and cymbal at first remained impulsive. But,
the therapist. Sophie was very insecure in the musical by the seventh session she came happy and expec-
pauses and immediately retreated from rhythmical im- tant directly to the piano where she played with more
pulses. However, in the fifth session she played more security.
often in relationship to the music, using both hands to A significant change came about in the eighth ses-
beat the drum in parallel and alternately. She was sion where she was constantly active and the musical
surer in the therapeutic relationship and made consid- aspects of her playing were more recognizable. She
erably more effort to play, even when it was manually could accompany, and play, changing tempi, decide
difficult for her. between loud and soft playing, repeat musical motifs
After this treatment period Sophie's mother de- and brought some continuity to her playing that was
scribed her as being much freer in daily life. For no longer spoiled by small distractions. Her acciden-
example, she investigated alone the family's newly tal changes were supported in the music so that they
acquired caravan. When travelling on the local bus, became parts of the musical whole, and she worked
she greeted the child next to whom she sat. When the hard to maintain the musical relationship.
door bell rang, she opened the door. When she In the following ninth session Sophie's playing
wanted to play with her mother she would find the sounded ambivalent and not so related as in the pre-
toys herself, a reverse of the previous situation. She vious week. She seemed withdrawn and unsure in
showed more initiative. Furthermore, although speak- what she did. However, by the next session she was
ing in a general babble, she could remember words restored to her previous level of progress and was able
and situations. If misunderstood, she would become to express herself in diverse musical activities. With
annoyed and show it. help, she was able to play the drum with parallel and
In the next treatment period her playing on alternative arm movements and by the final session

Intake Test1 Test? Test3 Test4

Kathleen

 David

A Sophie

+ Zena

X Tomrny

With No With No
MT MT MT MT
These changes are the individual changes in the overall Griffiths test score from when the
children were measured at intake. The intake score for each child is now the baseline, zero
for indicating further comparative changes from the original scores. The test scores, 1.2.3
and 4 are the changes in the Griffiths quotients for each child at three months, six months,
nine months @ o n e year following the inital measurement at intake. With MT = the
children had music therapy treatment before this test and after the last test. No MT = the
children had no music therapy prior to this test and after the previous test.

Figure 6. Changes in the Griffiths test scores for treatment group A from intake to final assessment

David Aldridge Collected music therapy papers 102


202 ALDRIDGE, GUSTORFF AND NEUGEBAUER

had many developed musical improvisational possi- both the above children can be seen in Figures 6 and
bilities at her disposal. 7, it is important to emphasize here the role of paren-
Sophie's mother described her daughter as being tal observation. When therapeutic change occurs, the
much more capable of playing with her brother, and primary arena for expression of that change is not
both able to dress herself and put on her shoes. Al- solely in the therapy room. What parents are expect-
though she was defiant when asked to repeat a word, ing is that children will be different at home. These
for instance, she babbled more and often repeated the changes are often subtle and too varied for a standard-
first syllable of a word that she had heard. Sophie was ized questionnaire. Therefore, the personal interview
more independent. On visiting a friend of her moth- with the parents is of equal importance for under-
er's, Sophie had gone to the refrigerator to fetch a standing changes in children. How we weave subjec-
drink when no one had understood that she was tive and objective results together is the creative na-
thirsty. She had become much more aware, and ap- ture of our inquiry, and we can do this once we have
peared to be surprised by her own capabilities. The established the criteria, fpr the way in which our data
consequences were that she became braver and more are collected.
energetic in taking new things on, would play with
others and sit next to her brother or her parents. On Discussion
going to bed, she took her teddy bear with her along
with other cuddly toys. For her mother it was a per- Children will develop. Some develop slower than
sonal breakthrough when Sophie allowed her hair to others, and for an even smaller minority that devel-
be cut and styled and agreed to wear a slide in her opment is delayed through a variety of causes. We
hair. argue, like others before us, that music therapy can
Although the individual developmental profiles of facilitate development and enhance its rate in those

Intake Test1 Test2 Test3

Suzie

No With No With
MT MT MT MT
These changes are the individual changes in the overall Griffiths test score from when the
children were measured at intake. The intake score for each child is now the baseline, zero
for indicating further comparative changes from the original scores. The test scores, 1.2.3
and 4 are the changes in the Griffiths quotients for each child at three months. six months,
nine months and one year following the inital measurement at intake. With MT = the
children had music therapy treatment before this test and after the last test. No MT = the
children had no music therapy prior to this test and after the previous test.

Figure 7. Changes in the Griffiths test scores for treatment group B from intake to final assessment.

David Aldridge Collected music therapy papers 103


CHILDREN WITH DEVELOPMENTAL DELAY 203

children whose development is in some way im- in the activity of making music that is important.
paired. When we speak of developmental change we Clearly, the activity of listening, in a structured mu-
are in the main speaking about the ability to commu- sical improvisational context, without the lexical de-
nicate either nonverbally or verbally. Indeed, the par- mands of language, is a platform for communicational
ents of the children treated in this study had an ex- improvement. The building blocks of language,
pectation that what they and their children did to- rhythm, articulation, sequencing (Alien, Barone &
gether would make some sense to them, that their Kuhn, 1993), pitch, timbre (Annett, 1993) and turn-
children could communicate needs, desires and emo- taking (Blampied & France, 1993) are musical in
tions, and that they, too, the parents and caregivers, nature. Focused listening to another person, we
could communicate their feelings to the children. That would argue, is also a prerequisite of effective mutual
Sophie could show both sadness and happiness were communication and dialogue. Furthermore, musical
considered to be important for her mother. That she dialogue in the music therapy relationship seems to
could also cuddle was a significant milestone in the bring about an improvement in the ability to form
emotional relationship of child and mother. and maintain personal social relationships in other
In this study we have gone some way to fulfilling contexts.
our first purpose in demonstrating that developmental Hand and eye coordination, which is dependent on
change can be perceived according to standardized a wider body awareness, appears to be the third vital
testing in the context of clinical research. The Grif- component in developmental change. That hand
fiths test is acceptable to us and to referrers in that movement plays such an important role is also sup-
it is based upon a broad base of clinical observa- ported by the literature emphasizing the role of non-
tions and makes sense when applied to the lives of verbal communication and gesture in the subtle as-
the children being assessed. Like music therapy it- pects of emotional expression (Barrett, 1993), the ac-
self, the emphasis is on eliciting the potential of the quisition of language (Millard et al., 1993) and in
children. cognitive development (Alibali & Goldin-Meadow,
We can say that children, when they partake in 1993; Goldin-Meadow, Alibali & Church, 1993). The
improvised creative music therapy, achieve signifi- active playing of a drum demands that the child listen
cant developmental milestones in comparison with to the therapist who in turn is listening to and playing
those children who are not treated. Later, when a for him or her. This act entails the physical coordi-
comparison group of children is treated, they too rap- nation of a musical intention within the context of a
idly achieve developmental goals. It must be men- relationship. We would argue that this unity of the
tioned here that at no stage in the study was music cognitive, gestural, emotional and relational is the
therapy targeted to specific developmental achieve- strength of active music therapy for developmentally
ments or aimed at particular behavioral activities. challenged children.
What we were interested in was what developmental In addition, the importance of the visual system in
changes took place, rather than trying to manipulate generating speech is necessary to bear in mind.
children so that targeted changes occurred. The rea- Shuren , Geldmacher and Heilman ( 1993) proposed
son for not specifying behavioral goals is that creative that there is a visual semantic system storing codes for
music therapy is not based on such a behavioral plan concrete words and picture names and a verbal system
of identifying specific clinical aims that would detract for conceptual knowledge of a more abstract type.
from the essential aim of making music together. As Both systems work together, yet the second is more
all the children were so completely different, as is the dependent upon internal stimuli or self-generated di-
nature of developmental delay, the same target vari- alogues. The activation of hand and eye together in
able could not apply to all the children. Furthermore, this study, visual-semantic and gestural, may have
as this was a preliminary study, we could not know had an influence on the speech-related practical-
what we were to focus on before we had made the reasoning sub-scale F, which all children exhibited by
study. However, there is a paradox inherent in cre- the end of the study.
ative music therapy in that we emphasize the musical The proximal zone, where child and therapist play
activity as paramount in therapy, yet it is the be- together, awakening a potential and extending the
havioral changes that we champion as therapeutic possibilities of the child, appears to be an important
success. concept for music therapy and is critical in achieving
Our initial purpose was also to discover what it is new creative possibilities in the therapeutic relation-

David Aldridge Collected music therapy papers 104


ALDRIDGE, GUSTORFF AND NEUGEBAUER

ship. Although the musical therapeutic relationship is The above work needs to be validated with a larger
the domain of this zone, the means of achieving this population of children and is best considered as a
relationship is in the encouragement of active listen- pointer in a general direction rather than as a conclu-
ing. Yet, such listening is also related to performing. sive statement. We found the clinical controlled trial
The intention to communicate is brought into a struc- to be a rather clumsy approach for our purposes. Even
ture so that communication can be achieved as per- a small number of children are radically different in
formance. In this case the structure is musical, has their capabilities. The treatment approach could not,
the advantage of flexibility and is built upon the ca- in practice, be blinded from the assessor in the first
pabilities of the individual child. His or her own ca- phase as parents would ask her when their child would
pabilities, no matter how limited, are brought into the eventually get to music therapy. What did emerge was
mutual realm of musical relationship with the thera- the importance of a reliable assessment instrument
pist and therefore are open to variety and, thereby, such as the Griffiths profile that could be systemati-
development. cally applied over longer treatment, and no treatment,
The caregivers of the children in this study said periods. Longitudinal single case designs would ap-
that a benefit of music therapy was that they could pear to be appropriate for further studies. Ideally, we
enjoy their children and what the children did began would have also used a child musical development
to make more sense. If through this "making sense" scale if one had been available. The Nordoff and Rob-
a child achieves independence by the expression of bins scales are not reliable instruments for compara-
needs, desires and wishes, and the ability to act ac- tive research, but they d o provide a guide to individ-
cordingly, then we have gone some small way in our ual assessment. For future researchers, it is important
study to demonstrate a benefit of creative music ther- to repeat that the interview with the parents or care-
apy. Listening and performing in the musical relation- givers is of equal value in that subtle individual and
ship, that is, action and purposeful movement in a relational changes are reported that would otherwise
relational context, appear to be the building blocks of escape the attention of a questionnaire or formal as-
developmental change and of relevance for cognitive sessment instrument. A qualitative study would em-
change. That these factors are pre-verbal, and not phasize in the future the relationship between the mu-
language dependent, would argue for the importance sical processes of change and the various changes as
of creative arts therapies in the treatment of develop- they occur in the life of the child at home. We would
mentally delayed infants. want to ascertain that patterns of communication oc-
Our secondary purpose was to find a suitable re- curring in the music therapy sessions could indeed be
search approach integrating quantitative and qualita- transferred to other situations with siblings or caregiv-
tive methods. We have used empirical data that can be ers.
analyzed statistically, but, as in all statistical meth- Although we can make generalizations from the
ods, the analysis must be applied and interpreted. By above work, it is important for music therapists as
using multivariate techniques, we have chosen to in- researchers to stay in contact with the single child.
vestigate the relationship between variables as shown This does not invalidate group research methods. As
by our data. The relationship between variables, al- we see here, the comparison of groups has alerted us
though suggested as significant by the analysis, must to significant changes. Hopefully, future research will
be interpreted as clinically significant by the re- reflect the creative tensions between generalizibility
searcher and further validated by the clinicians. As and specificity-what we can say about music therapy
Dzurec and Abraham (1986) remarked: with children in general and what happens to the in-
dividual child in the process of therapy. Quantita-
In other words, for the researcher using multi- tively, we have assessed changes through the collec-
variate analysis, as for the researcher using phe- tion of data according to a particular instrument, the
nomenology, meaning is not inherent in data as Griffiths test. Qualitatively, we have interpreted those
they are analysed, but is implied by the re- data to develop inferences from what is observed.
searchers view of reality and the construction of
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David Aldridge Collected music therapy papers 106


Music and Medicine
2(1) 41-47
Psychometric Results of the Music Therapy ª The Author(s) 2010
Reprints and permission: http://www.
sagepub.com/journalsPermissions.nav
Scale (MAKS) for Measuring Expression and DOI: 10.1177/1943862109356927
http://mmd.sagepub.com
Communication

Dorothee von Moreau, Dr. rer. medic., music therapist (bvm, DMtG), Dipl.
Psychologist,1 Heiner Ellgring, Dr. rer. nat., Dipl. Psychologist,2
Kirstin Goth, Dr. phil. nat., Dipl. Psychologist,3
Fritz Poustka, Prof. Dr. med., Professor emeritus,3 and
David Aldridge, PhD, FRSM4

Abstract
The Music Therapy Rating Scale (MAKS), originally developed in 1996, was evaluated again in 2009 using a sample of 62 children
from a psychiatric unit and from different primary schools, with measures at three different time points during therapy process.
The scale is intended as an objective rating of a client’s musical behavior. The evaluation of the scale was to determine any possible
ambiguity or weakness in the discriminatory power of the scale items. After excluding such items, the results show high reliability
(a > .75) and good objectivity with trained raters (r > .70) for the two main scales and a significant sensitivity to change.

Keywords
musical communication, musical expression, music therapy, rating scale MAKS

There has been an urgent need for evaluation in music therapy As specific music therapy rating scales, Bruscia’s Improvi-
over the past years, and specific assessment instruments for sation Assessment Profiles are often used in music therapy
music therapy are still missing, especially for patients who can- research in English-speaking countries (Bruscia, 2001), but
not be evaluated by verbal tests (Aldridge, 1996; Tischler, these have yet to be validated. Maler’s (1989) scale is partly
2000). It is important in clinical practice that we describe in validated but is very complicated in applying ratings and is
detail the patient’s mental state and psychic structure. There- no longer implemented. The Nordoff/Robbins rating scales
fore, we need to identify specific criteria for the assessment (Nordoff, Robbins, Fraknoi, & Ruttenberg, 1980a, 1980b),
of a client’s musical expression. The question remains as to used primarily with children with disabilities, are now under
how we interpret what we hear in a musical context in terms evaluation. Schumacher’s Assessment of the Quality of Rela-
of both relationship and expression and the implications of this tionship (Schumacher, 1999; Schumacher & Calvet, 2007;
interpretation for therapy. Schumacher & Calvet-Kruppa, 1999) is currently being evalu-
ated for its application to people with mental disorders
Music Therapy Rating Scales other than autism. Pavlicevic’s Music Interaction Rating scale
(Pavlicevic, 1991, 2007), describing the patient’s level of con-
Music therapy rating scales already exist in the literature (for an tact during musical improvisation in music therapy, has been
overview, see Phan Quoc, 2007; Sabatella, 2004). Many of validated for use with psychiatric patients. The challenge of
them, however, are neither specific to music therapy nor vali-
dated. In Germany, semantic differentials are often used for
describing improvised music during music therapy interven-
tion. These differentials are bipolar adjective lists with scales 1
Freies Musikzentrum, Munich, Germany
divided into five or seven intervals to rate a subjective impres- 2
University of Würzburg, Würzburg, Germany
3
sion of what is heard. They were used by music therapy Goethe University, Frankfurt am Main, Germany
4
researchers in the 1990s due to a shortage of specific scales for Nordoff-Robbins-Zentrum, Witten, Germany (nordoff_robbins@mac.com)
music therapy (Burrer, 1992; Inselmann & Mann, 2000; Pechr,
Corresponding Author:
1996; Steinberg & Raith, 1985; Steinberg, Raith, Rossnagel, & Dorothee von Moreau, Institut für Musiktherapie, Freies Musikzentrum,
Eben, 1985; Vanger, Oerter, Otto, Schmidt, & Czogalik, 1995; Munich, Germany
Zahler, 2002). Email: dvmoreau@web.de

David Aldridge Collected music therapy papers 107 41


42 Music and Medicine 2(1)

Table 1. The Music Therapy Rating Scale (MAKS): Expression and For scoring purposes, all items were divided into seven lev-
Communication Subscales els. Each level was operationalized, creating precise descrip-
MAKS tions to avoid ambiguity (of some items; see Table 2).
This scale was validated in 1996 by an initial evaluation pro-
Expression scale: Communication scale: cess with 52 raters on the basis of 10 video scenes of different
rating improvised solo rating improvised duo playing adolescent patients in a psychiatric clinic (Moreau, 1996,
playing (14 items) with the therapist (13 items) 2003). Scores allowed significant differentiation between cli-
(Dealing with the instrument) (Engagement) ents with various psychiatric disorders (p < .001). The results
Range of melody (TR) Autonomy (AT) for objectivity (mean interrater correlation: Kendall’s tau ¼
Initiative (IN) Inner participation (BT) .4 for the Expression scale and .3 for the Communication scale)
(Form/musical figure) (Formal aspects) needed to be improved, but the retest results suggested that a
Form (FG) Need of space (RA) training of the raters may slightly improve the score for
Structure (ST) Length of playing intervals (DA)
objectivity.
Variation (VR) Logic structure (LA)
(Vitality/dynamics of expression) (Regarding the other) The experiences of Plum (Plum, Lodemann, Bender,
Suspense/tension (SP) Reference (BZ) Finkbeiner, & Gastpar, 2002) and Isermann (2001), testing the
Power (SK) Intensity of contact (KI) practicability of the scale in a clinical context with adults with
Vitality (LB) Contact behavior (KV) schizophrenia, encouraged us to revise the scale and to reeval-
Flow (SF) Variability in acting (VV) uate it in a clinical setting.
Dynamics (DY) Dominance (DO)
(Quality of expression) (Quality of expression)
Sound quality (KQ) Quality of flow (DQ) Aim and Hypotheses
Quality of expression (AU) Quality of affects (AQ)
The main task of the actual study was to evaluate the MAKS
Clarity of emotions (EA) Quality of play (SQ)
Resonance/involvement (EL) again with trained raters, according to the general psychometric
criteria of objectivity and reliability and to establish its useful-
Hypothetical categories are in brackets. ness, clinical applicability, and relevance.

1. Testing reliability shows to what extent the scales are free


measuring the music therapy outcome with young and adoles- of measurement error. The a priori criterion for accepting
cent psychiatric patients, however, has not been addressed. reliability according to psychometric standards (see Bortz
A question remains about whether scales, conceptually & Döring, 2006) was set at a Cronbach’s alpha greater than
based on developmental psychology, are appropriate for chil- .75.
dren without developmental disabilities or severe psychiatric 2. The objectivity of a scale shows to what extent the raters
disorders, but who are, nevertheless, unstable in both emotional agree in their judgment. The a priori criterion for accepting
expression and social interaction. We identified the need for a objectivity according to psychometric standards was set at
music therapy rating scale specifically for measuring musical a Pearson’s interrater correlation greater than .7.
behavior on more than one dimension in order to depict the cli- 3. Sensitivity to change shows to what extent the scale will
ent’s behavior that included dissent, inconsistency, and detect the development of the client’s musical expression
ambivalence. A rigorous scale could then be used for the initial or communication skills throughout the duration of ther-
assessment process and for a final assessment at the end of ther- apy. The a priori criterion for accepting the hypothesis was
apy, making it a useful tool for an evaluation of therapy out- significance (tested by MANOVA with the factors Psycho-
come. While we have diagnostic scales, we have no rating pathology and Time of Measurement), p < .05, for the
scales for assessing therapeutic change. within-subject factor Time.

Methodological Design
Development of the Scale and First Results of Validation Procedures
Development of the Music Therapy Rating Scale (MAKS)
began in 1994 with a survey of music therapy experts (Moreau, For the rating of the children’s musical behavior, we produced
1996). In a process of item testing and reduction, the scale has video recordings of each child in a standardized assessment
been modified in clinical practice for several years. For the session of about 15 minutes at three measurement points in
final version, the MAKS was composed of two subscales. One, time (t1 ¼ at the beginning, t2 ¼ in the middle, and t3 ¼ at the
the Expression scale, is 14 items for rating a client’s improvi- end of music therapy treatment or music workshop). In each
sational musical performance in a solo playing. The second, the assessment session, the child was asked to play by hand a large
Communication scale, is 13 items for rating a client’s improvi- African drum alone, and then in a second episode to play it
sational musical performance in duo playing with the therapist together with the therapist. During the duo play, the therapist
(for an overview of the scale’s categories see Table 1). was instructed to answer the child’s offering on contact with

42 David Aldridge Collected music therapy papers 108


Moreau et al. 43

Table 2. Music Therapy Rating Scale (MAKS) Item Examples: Expression and Communication Subscales

Expression scale: Initiative (frequency of the client’s own ideas)


No initiative (only plays Very low-level initiative Low-level Normal High-level Very high-level Extreme-level initia-
when requested and/or (reproduces only familiar initiative initiative initiative initiative (more tive (cannot restrain
offered assistance) musical patterns) (1-2 ideas) (2-3 ideas) (3-4 ideas) than 4 ideas) him- or herself)

Communication scale: Dominance (level the client places him- or herself under or above the therapist)
Strongly subordinate Moderately A little Equal A little Moderately Strongly dominating
(does not play or falls subordinate subordinate dominating dominating (overwhelming)
silent) (conformist) (partly (decisive, (influential)
conformist) inviting)

empathy and to stay cautious neither to force nor to push the Distribution of main diagnoses
child’s reactions more than necessary. From the videos of each 30
assessment session, the therapist chose a representative scene
of solo playing of 20 to 30 seconds for the rating of musical 25
expression and a representative scene of duo playing with the
therapist of 30 to 40 seconds for the rating of musical commu-
nication. The therapist decided which part of the video was typ- 20
ical or representative of the child’s behavior at that time of
treatment. Finally, we had six video episodes for each partici- 15
pant, containing one solo and one duo scene from each time
segment (t1, t2, t3). These video scenes from all children were
assembled in random sequence and recorded on CDs for rating 10
by three independent observers who had been trained in using
the MAKS. These raters, three music therapy colleagues from 5
different music therapy training backgrounds and with 3 to 5
years’ music therapy experience with children, watched the
videos and scored the musical behavior of the children using 0
F90 F91 F92 F93 F94 F98 F84 F44 healthy
the MAKS.
Figure 1. Main diagnoses (International Classification of Diseases,
Instruments Version 10) of the children’s sample.

For the evaluation of the children’s improvisational solo and


of 3 to 4 months. We selected only boys and only those children
duo play, we used the Expression and Communication scales
without impaired intelligence to assure that the groups were
of the MAKS, as described above. In addition, the children’s
homogeneous in gender and cognitive ability—although the
parents filled out a personality questionnaire, the Junior
children differed in age (see Table 3).
Temperament and Character Inventory (JTCI 7-11 R; Goth,
Neither group differed in creativity (ANOVA p ¼ .958, tested
Cloninger, & Schmeck, 2003; Goth & Schmeck, 2008). The
by JTCI 7-11 R), but they differed significantly in all other cate-
personal nurse at the hospital or the parents, for the nonclinical
gories of temperament and character (ANOVA p < .010, tested
group, filled out a short psychopathology questionnaire, the
by JTCI 7-11 R). We found significant differences in the SDQ
Strengths and Difficulties Questionnaire (SDQ; Goodman,
total score (w2 test p ¼ .025), in the categories prosocial behavior
2001; German translation, Woerner et al., 2002).
(w2 test p ¼ .000) and problems with peers (w2 test p ¼ .008).
However, to our surprise, there were aspects of psychopathology
Participants in both groups. Some healthy controls displayed severe or minor
Thirty-eight inpatients from a university hospital for child and social and emotional problems. The clinical group was poorer in
adolescent psychiatry attended group music therapy sessions both psychosocial adaptation and social skills.
over a period of 4 weeks to 10 months, depending on the length
of their hospital stay. Most of the patients had a main diagnosis
Results
of hyperkinetic disorder, F90, according to the International
Classification of Diseases, Version 10 (ICD-10), and most had Reliability
multiple diagnoses (see Figure 1).
In addition, 24 healthy children from different primary The results for scale reliability were taken from the data of the
schools attended a music workshop of 10 sessions over a period 62 children’s first assessments (t1) at the beginning of therapy.

David Aldridge Collected music therapy papers 109 43


44 Music and Medicine 2(1)

Table 3. Characterization of the Clinical Sample criterion (marked by the black line; see Figure 2) in one of the
contexts (initial study in 1996, after training situation, and
Inpatient participants Control participants
(n ¼ 38) (n ¼ 24) actual study)—except those items that were already mentioned
in case of reliability: FG (form), ST (structure), and EA (clarity
Age (years, months) 9, 9 (+1, 7) 8, 1 (+1, 5) of emotions). In the Communication scale, we identified the
Sex Male Male items KI (intensity of contact) and DQ (dynamic quality) as not
The intelligence score (IQ) in the clinical group was taken from axis III of the showing sufficient psychometric properties.
International Classification of Diseases, Version 10 (Remschmidt et al., For the total score analysis of the Expression scale and the
2002). In the healthy group, IQ was controlled by school. Communication scale, we used only those items with sufficient
discriminatory power and that loaded on a stable factor in the
Table 4. Reliability of the Expression (A) and Communication (K) factor analysis. Based on this selection criteria, the total score
Subscales for Each Rater (G, C, B) of the Expression scale, (without items FG ¼ form, ST ¼ struc-
ture, EA ¼ clarity of emotions) showed an interrater correlation
G C B
of r ¼ .9, and the total score of Communication scale (without
Expression scale items RA ¼ need of space, DA ¼ length of playing intervals,
A: alpha .80 .72 .75 BZ ¼ extent of extraverted or introverted orientation or refer-
(rit) FG (.23) FG (–.20) FG (.11) ence) was r ¼ .7.
ST (–.16) ST (–.01) ST (–.22)
EA (.15) EA (.21)
A: alpha* .88 .83 .83 Sensitivity for Change
A: rit-range* .39-.74 .36-.74 .27-.81 (KQ) We tested sensitivity for change by MANOVA analysis with
Communication scale
K: alpha .85 .76 .81
the factors Psychopathology (SDQ total score) and Time of
(rit) DA (.01) DA (.03) DA (.11) Measurement (t1, t2, t3). For this analysis, we took the MAKS
BZ (.08) BZ (.13) BZ (–.02) Expression total score and the MAKS Communication total
K: alpha* .88 .78 .84 score (all items of each scale except the weak items, as
K: rit-range* .34-.85 .21-.64 (KV) .23-.72 (LA) described above). The analysis of the solo plays showed
For the subscales, alpha and rit ¼ results for all items; alpha* and rit-range* ¼
significant changes over time in musical expression (within-
results with reduced items. FG ¼ form; ST ¼ structure; EA ¼ clarity of emo- subject factor time: p ¼ .023). Analyzing the duo plays, we had
tions; DA ¼ length of the play the client takes compared to the therapist; BZ ¼ even stronger effects of significant changes in musical commu-
reference or extent of extraverted or introverted orientation. nication (within-subject factor time: p ¼ .001). We can con-
clude that the MAKS is sensitive to discrete changes in
musical expression and communication.
We analyzed the ratings of each single observer separately to
get an idea of the stability of these results. A first analysis on
all items of the Expression scale and all items of the Commu- Discussion
nication scale showed a Cronbach’s alpha coefficient greater After excluding the weak items for all total score analyses, the
than .70, but the corrected item total correlations of some items total scores of the Expression scale and the total scores of the
were below the criterion of .3 (see Table 4). Communication scale present sufficient objectivity and relia-
As these items (FG ¼ form; ST ¼ structure; EA ¼ clarity of
bility. The results on the level of item with different training
emotions; DA ¼ length of the play the client takes compared to
conditions suggest that good training is absolutely necessary
the therapist; and BZ ¼ reference or extent of extraverted or
for using the scale.
introverted orientation) also had low objectivity scores, they were
The items of form (FG) and structure (ST) did not show
removed for a new analysis (in Table 4, see alpha* and rit- sufficient interrater, nor corrected total item correlations.
range*). The results then fulfilled the criterion alpha of greater These items are ambiguous in operationalization, difficult
than .75, and the range of the corrected item total correlation was to rate, and do not contribute to explaining musical expres-
improved too. sion skills. Other items like length of the play the client
takes compared to the therapist (DA) and the extent of
extraverted or introverted orientation (BZ) need better train-
Objectivity ing. Children in a psychiatric setting often change their
The scale’s objectivity was measured by the interrater correla- orientation while playing with an adult person and hardly
tion of all three raters (Pearson’s coefficient) for each single show stable patterns.
item to detect nonobjective items. We took the data of all chil- The items clarity of emotions (EA) or intensity of contact
dren and all assessment sessions. These results were compared (KI) can be removed from the scale. Ratings of intensity of
to the results gained in the first evaluation process (Moreau, contact or clarity of emotions do not depend on observable
1996), and the results gained immediately after the rater train- behavior but on the rater’s personal impression. The scale has
ing. Almost all items of the Expression scale fulfilled the limitations when asked to portray the quality of various

44 David Aldridge Collected music therapy papers 110


Moreau et al. 45

0.7

0
TR IN FG ST VR SP SK LB SF DY KQ AU EA EL

0.7

0
AT BT RA DA LA BZ KI KV VV DO DQ AQ SQ

actual study training initial study

Figure 2. Objectivity (Pearson’s correlation coefficient ¼ y-axis) of the items (x-axis) of the Expression scale (Figure 2a) and the
Communication scale (Figure 2b).

emotions or the intensity of contact between persons. On the during music therapy. As an interval scaled rating instru-
other hand, the item inner participation (BT), operationalized ment, the scale allows strong statistical methods for data
by attention, is easier to observe. analysis. When the week items are eliminated, the scale ful-
The MAKS is a rating scale constructed by music therapy fills the necessary psychometric standards of reliability and
experts specifically for evaluating music therapy. The accurate objectivity when it is used by well-trained raters. It is sen-
description of each interval of the items allows a detailed sitive to change and can portray a child’s development dur-
reflection of a client’s musical behavior. Therefore, the MAKS ing therapy.
is more precise than semantic differential tests and presents a For further research, we have to determine group-specific
wider field of musical expression or communication skills as characteristic profiles with regard to diagnosis, age, and/or gen-
the scales examine more than one aspect of behavior. Inconsis- der to be able to give a clear diagnostic statement related to a
tent, or contradictory behavior of the client may be portrayed patient’s MAKS profile.
comparing the solo- and the duo-playing conditions and also
comparing different aspects of musical expression, for exam-
ple, tension (SP) and loudness (SK), or tension (SP) and move- Declaration of Conflicting Interests
ment (LB). The author(s) declared no potential conflicts of interests with respect
to the authorship and/or publication of this article.

Conclusion Funding
The MAKS is a scale constructed specifically to evaluate We would like to thank Andreas-Tobias-Kind-Stiftung, Hamburg,
the musical expression and communication skills that occur Germany, for financial support for this study.

David Aldridge Collected music therapy papers 111 45


46 Music and Medicine 2(1)

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David Aldridge Collected music therapy papers 113 47


J Autism Dev Disord (2007) 37:1264–1271
DOI 10.1007/s10803-006-0272-1

ORIGINAL PAPER

Use of Songs to Promote Independence in Morning Greeting


Routines For Young Children With Autism
Petra Kern Æ Mark Wolery Æ David Aldridge

Published online: 22 November 2006


 Springer Science+Business Media, LLC 2006

Abstract This study evaluated the effects of individ- Introduction


ually composed songs on the independent behaviors of
two young children with autism during the morning Providing early intervention services to young children
greeting/entry routine into their inclusive classrooms. with autism spectrum disorders is supported by sub-
A music therapist composed a song for each child stantial research and program evaluation data (Dawson
related to the steps of the morning greeting routine and & Osterling, 1997; National Research Council, 2001).
taught the children’s teachers to sing the songs during Some of this research argues for providing services in
the routine. The effects were evaluated using a single inclusive classes in community-based programs (Strain,
subject withdrawal design. The results indicate that the McGee, & Kohler, 2001). However, for children with
songs, with modifications for one child, assisted the autism to benefit from such placements, attention must
children in entering the classroom, greeting the teacher be given to their individualized learning needs (Strain
and/or peers and engaging in play. For one child, the et al., 2001).
number of peers who greeted him was also measured, Children in early childhood classes experience
and increased when the song was used. multiple transitions each day between activities and
routines as well as to and from the classroom. Exam-
Keywords Music Therapy Æ Child Care Program Æ ples are initial arrival at the classroom, engaging in
Inclusion Æ Autism Æ Transitioning Æ Collaborative play, moving from one area of the classroom to
Consultation another, going outdoors and coming back from out-
doors, moving to a snack area, and going to a cot for
naptime (Alger, 1984; Baker, 1992). Young children
often spend large amounts of time in these classroom
P. Kern transitions (Carta, Greenwood, & Robinson, 1987).
Frank Porter Graham Child Development Institute, For many young children with and without autism, the
University of North Carolina at Chapel Hill, initial transition into a classroom each day can result in
Chapel Hill, USA
crying, clinging to the caregiver, and active avoidance
M. Wolery of the class. Their parents and other caregivers may be
Department of Special Education, uncertain about how to respond to these behaviors
Vanderbilt University, Nashville, USA (Alger, 1984). These behaviors also may result in
similar reactions from classmates and avoidance of the
D. Aldridge
Chair of Qualitative Research in Medicine, entering child (Osborn & Osborn, 1981).
University of Witten-Herdecke, Witten, Germany Transitions, including the initial daily transition into
the class, may be difficult for young children with
P. Kern (&)
autism (Dawson & Osterling, 1997; Mesibov, Adams,
School of Music, University of Windsor,
401 Sunset Avenue, Windsor, ON, N9B 3P4, Canada & Klinger, 1997). In addition, they may lack an
e-mail: PetraKern@prodigy.net understanding of symbolic gestures such as waving

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David Aldridge Collected music therapy papers 114
J Autism Dev Disord (2007) 37:1264–1271 1265

hello or good-bye or at least may engage in these apply the principles important to music therapy in a
greeting behaviors less than age mates (Hobson & Lee, particular routine, and (3) Does use of the song
1998). Recommended strategies for promoting suc- increase interactions between the child with autism and
cessful transitions of children with autism include using his peers?
(1) structure and predictable routines (Marcus, Scho-
pler, & Lord, 2001; Trillingsgaard, 1999), (2) visual
cues (Bryan & Gast, 2000; Schmit, Alper, Raschke, & Method
Ryndak, 2000), and (3) songs (Baker, 1992; Furman,
2001; Gottschewski, 2001; Williams, 1996). Participants
Songs are a common occurrence in early childhood
classes and are used by a wide range of professionals for Two boys, Phillip and Ben, with autism participated in
skill promotion, entertainment, and expression of the study. Phillip was a 3 year 5 month-old African
emotions (Enoch, 2001; Furman, 2001; Humpal, 1998). American, and Ben was a 3 year 2 month-old Euro-
In music therapy, ‘‘hello’’ and ‘‘good-bye’’ songs are pean American. Licensed psychologists who were not
used frequently to establish predictable routines and involved in the study used the DSM-IV criteria
structure, provide undivided attention, and communi- (American Psychiatric Association, 2000) when estab-
cate a welcome (Bailey, 1984; Nordoff & Robbins, lishing their diagnoses. On the Childhood Autism
1995). Using songs to promote successful transitions is Rating Scale (Schopler, Reichler, & Renner, 1988),
recommended for young children with autism (Furman, both boys were placed in the mild to moderate range.
2002; Humpal & Wolf, 2003; Snell, 2002), but no pre- Prior to the study, Phillip and Ben had been enrolled
vious study evaluated greeting and good-bye songs on for 10 months in an inclusive community-based child
the performance of young children with autism during care program affiliated with an university. They were
the morning arrival time. selected for the study on the request of their parents
Studies on interest in music and relative strength of and classroom teachers and therapists.
musical abilities in some children with autism Both boys had limited speech, and the Picture
(Applebaum, Egel, Koegel, & Imhoff, 1979; Thaut, Exchange Communication System (PECS) (Bondy &
1987, 1988) and the effectiveness of music therapy Frost, 1994) was being used. Ben was beginning to use
interventions (Bunday, 1995; Kostka, 1993; Wimpory, a few functional words. Phillip and Ben showed limited
Chadwick, & Nash, 1995) suggest music therapy is a social interactions with peers, played primarily when
viable treatment option for individuals with autism. supported by adults, and engaged in stereotypic
For instance, songs have been used to supplement the behaviors. Both children exhibited difficulties with
use of social stories to support social interaction in transitions, although objects were used successfully
children with autism (Brownell, 2002; Pasiali, 2004). with some transitions other than the morning arrival
Key recommendations for educating young children transition. The morning arrival transition was prob-
with autism (e.g., individualization, structure and pre- lematic for both boys. Phillip would refuse to enter the
dictability, emphasis on strengths and individual needs) classroom, scream, or lie on the floor. Ben would hold
can be incorporated in music therapy protocols or are on to his caregiver, cry, and ignore efforts of the
part of the nature of music itself (American Music teachers to welcome him. Phillip and Ben were inter-
Therapy Association (AMTA), 2002). Although not ested in and responded well to music. They preferred
studied systematically, music therapy can include listening to selected musical pieces, and participated in
embedding music therapy principles and strategies into classroom musical activities.
ongoing routines of children’s days using a collabora- Other participants included the target children’s
tive and consultative model of service delivery classmates with parental consent (n = 13), the target
(Furman, 2001, 2002; Snell, 2002). children’s respective caregivers (n = 2), and classroom
The purpose of this study was to evaluate the effects teachers (n = 5). The class size of Phillip’s class was
of individually composed greeting songs implemented seven children (including him) ages 2 to 3 years and
by classroom teachers on the independent performance included both males and females from different ethnic
of two young children with autism during the morning groups. Five of his classmates were developing typi-
greeting routine. Three research questions were asked: cally, and one had disabilities. Ben’s class had eight
(1) Does the use of an individually composed song, children (including him) ages 3 to 4 years and
sung by teachers, increase appropriate independent included both males and females from different ethnic
performance during the morning arrival routine of groups. Five of the children were developing typically
young children with autism; (2) Can classroom teachers and two had disabilities. All adults in the classroom

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David Aldridge Collected music therapy papers 115
1266 J Autism Dev Disord (2007) 37:1264–1271

participated based on their schedules, which included teachers and peers, regardless of their language and
staggered start times to cover the entire child care communication skills when entering the classroom in
day. They had diverse educational backgrounds, the morning.
ranging from high school diploma to Baccalaureate The first author composed a greeting song unique to
degree with certification in early childhood education. each target participant.1 The music was composed to
Their teaching experience ranged from 1 to 4 years. match each child’s personality with the lyrics convey-
Phillip and Ben’s caregivers (a mother and nanny, ing the demands of the desired five-step morning
respectively) participated in the study on a daily basis greeting routine (see below). To emphasis the
by bringing them to their classrooms and participating detachment from the caregiver, step four, which
in the greeting time procedures. The teachers and reflected the ‘‘good-bye’’ part, differed musically in
caregivers did not have prior experience with music melody and mood from the other steps. All other steps
therapy interventions. followed the same melody, but used different lyrics.
Some of the lyrics were flexible to allow the children
Setting to choose different peers and describe the daily
weather condition. A practice CD containing the song
The inclusive university-affiliated child care program in and the song transcriptions were given to the teachers
which the study occurred held accreditation from the and caregivers during a staff/caregiver training session.
National Association for the Education of Young The intention of the songs for both children was to
Children (NAEYC) and the State’s highest quality ease the transition from home to school, to increase
ranking for child care programs. The classrooms their independent performance (i.e., independent
followed the recommended practice guidelines of functioning) during the five-step morning greeting
NAEYC (Bredekamp & Copple, 1997) and the Divi- routine, and to support their interaction with peers
sion for Early Childhood (Sandall, McLean, & Smith, (i.e, engaging in greeting peers).
2000). Specialists such as music therapists, occupa-
tional therapists, speech language pathologists, physi- Design
cal therapists or special educators worked with the
individual child or a group of children in the ongoing Single subject research designs were used. For Phillip,
classroom routines or as a consultant to the classroom an A-B-A-B withdrawal design (Aldridge, 2005;
teachers (McWilliam, 1996). Cubbies for children to Tawney & Gast, 1984) was used. The baseline con-
place their personal items were located in the hall dition (A) consisted of the existing greeting routine,
outside each classroom. and the treatment (B) involved using the song during
The study occurred during the morning greeting the greeting routine. For Ben, a modification of this
routine. In the mornings, children arrived individually design was used; specifically, an A-B-C-A-C design.
over a 1.5 h period. The usual routine was for each The baseline (A) was the existing greeting routine,
child, and his/her parent, to place personal items in the the treatment (B) was the use of the song during the
child’s cubby and then enter the classroom together. greeting routine, and the C condition was a modifi-
All children would be greeted by, and greet, the tea- cation of the song. Staff/caregiver training activities
cher and peers, then engage in play. The classroom occurred prior to baseline measures.
curriculum allowed free play during the morning arri-
val time. Children engaged in different play areas by Baseline Condition (A)
themselves or with each other. The parents signed the
child in and had a brief conversation with the teacher In the baseline condition, the child and caregiver
before saying ‘‘good-bye’’ to the child and leaving the entered the center, placed the child’s belonging in his
classroom. cubby in the hallway, and picked up the picture
symbol showing the stick figure waving ‘‘Hello,’’
Materials which was attached with Velcro to the child’s cubby.
They then entered the classroom, and a classroom
Before the study, the teachers used a laminated picture teacher initiated the greeting routine, which was
(10 · 10 cm) communication symbol (Mayer-Johnson, similar to that used with classmates. Five steps were
1992) showing a waving stick figure and the word followed: (1) the target child enters the classroom
‘‘Hello’’ printed on the top using 18 pitch letters and
the Arial font. This symbol was used in the study to 1
Interested readers can contact the first author to get a music
assist the target participants in greeting classroom score.

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David Aldridge Collected music therapy papers 116
J Autism Dev Disord (2007) 37:1264–1271 1267

independently; (2) the target child greets a person ‘‘good-bye’’) was eliminated, and his caregiver left the
(teacher or peer) in the classroom verbally and/or classroom as Ben entered it. Other procedures
hands over the picture symbol; (3) the target child remained the same.
greets a second person (teacher or peer) in the
classroom verbally and/or hands over the picture Response Definitions and Measurement
symbol; (4) the target child says/waves ‘‘good-bye’’ to
the caregiver, who leaves the classroom; and (5) the Two adult behaviors and five child behaviors were
target child engages in appropriate play with a toy or measured through direct observation using event
material found in the classroom. A system of least recording. Data were collected during morning arrival
prompts (Wolery, Ault, & Doyle, 1992) was used to time, when the teachers and peers were present. The
assist the target child in responding independently to observation started when the target child and his
each step of the greeting routine and ensure the child caregiver entered the classroom. The observation
completed each step of the routine. ended when the target child picked up a toy/material in
the classroom, even if he had not said ‘‘hello’’ or
Staff/Caregiver Training Activities ‘‘good-bye.’’ Data collection sessions lasted between 2
and 10 min. Phillip was observed for a total of 28 ses-
Initially, the first author consulted with the caregivers sions across 2 months. Data collection for Ben was
and teachers to identify realistic intervention goals and initiated 5 months later, and occurred in 31 sessions
acceptable procedures for use in the greeting routine. over 3 months.
Before baseline measures, she composed and recorded The adult behaviors were: Prompting was defined as
the individual songs, and gave them to the caregivers a teacher or caregiver assisting the child in performing
and teachers. During a circle time in the children’s a step in the routine. This assistance was either verbal
classrooms, the first author led the children and (e.g., ‘‘Say, Hello’’) or physical (e.g., the adult put her
teachers in learning and singing the songs. She also hand on the child to help in the exchange of the pic-
gave precise instructions to the teachers and caregivers ture). No adult prompt was defined as the teacher or
about how to approach and assist the target children in caregiver not giving a prompt for a step of the greeting
greeting and interacting with peers musically. The routine.
teachers were encouraged to include all peers who The child behaviors for each step of the routine
would come forward voluntarily to greet the target were as follows. Independent response was defined as
child in the greeting routine during all phases (baseline, the child performing the behavior required in each
intervention, and reversal). Staff training ended after step of the routine without any adult assistance.
2 weeks when the teachers and respective caregiver Prompted response was defined as the child perform-
sang the song correctly and indicated that they were ing the step of a routine but receiving adult prompt to
comfortable with the procedures. do so. No response was defined as the child not
responding, even when prompted. Error was defined
Intervention (B) as the child either not following the sequence of the
routine or engaging in an appropriate behavior not
In the intervention condition, the procedures used in prescribed by the routine, and Inappropriate response
the baseline were continued. The only change was the was defined as the child engaging in problematic
use of each child’s greeting song. The songs had lyrics behavior (i.e., tantrums). These categories were coded
matching each of the five steps of the greeting routine. for each of the five steps of the morning greeting
The teacher began singing the song as the child entered routine. An additional category was added for Ben to
the classroom, and sang the lyrics for each step as it identify the number of classmates with and without
was occurring. disabilities who greeted him independently during the
routine. This category was added because of informal
Modified Intervention (C) observations with Phillip indicating peer greeting
behavior changed during the course of the interven-
For Ben, the number of independently completed steps tion. The number of peers greeting independently was
did not change substantially with the introduction of defined as peers receiving the ‘‘Hello’’ symbol from
the song. Based on an analysis of the situation, we Ben without verbal or physical prompting from an
concluded Ben began to cry when separating from his adult. Some observations were videotaped with a
caregiver and this interfered with independent perfor- Panasonic AG-195 Camcorder and analyzed immedi-
mance of the steps. Thus, the fourth step (saying ately afterwards.

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1268 J Autism Dev Disord (2007) 37:1264–1271

Observer Training and Interobserver Agreement Phillip’s performance steadily moved toward indepen-
dence. After 10 sessions in intervention, Phillip’s per-
Before the baseline condition, a music therapist (first formance appeared consistent, as evidenced by three
author), a special educator and a research assistant consecutive sessions with four independent steps at the
observed and recorded the behaviors of teachers and same level; thus, the intervention was withdrawn.
children in the morning greeting routine. Training was Phillip’s performance immediately decreased and by
concluded when inter-observer agreement was at 80% the second day of the second baseline condition, his
for three consecutive observations. During the study, performance returned to the initial baseline levels with
inter-observer agreement checks occurred in a mean of two independent steps (again entering the classroom
22% of the observations for each condition and child. and finding a toy to play with). After three days, the
The percentage of agreement was calculated using the song intervention was re-introduced. Immediately,
point-by-point method (Tawney & Gast, 1984). The Phillip’s performance increased. After four sessions,
number of agreements were divided by the number of Phillip’s performance was equal to his performance at
agreements plus disagreements with the quotient the end of the initial intervention condition. His per-
multiplied by 100. Overall, inter-observer agreement formance remained steady at this level until the ninth
ranged from 75 to 100%, with a mean of 94%. session of intervention where Phillip performed all of
the steps of the routine independently.

Results Ben

Phillip In the initial baseline condition, Ben’s performance was


stable as shown in Fig. 2. In the majority of the sessions,
During the initial baseline condition, Phillip’s perfor- he had one independent step completed, entering the
mance was stable as shown in Fig. 1. In all sessions classroom independently. On session four of the first
except the fourth, Philip completed two steps of the baseline condition, Ben did three independent steps.
routine independently. In the fourth session, he did not With the introduction of the song intervention, Ben’s
do any step independently. The steps he did indepen- performance was variable. Ben responded in the
dently were entering the classroom and finding a toy majority of sessions with one independent response, as
with which to play. With the introduction of the song in the baseline condition. In four of 12 mornings, Ben
intervention, Phillip’s performance initially dropped to completed more than one of the steps independently.
one step independently (entering the classroom), but Given the lack of substantial change in his performance,
after two days of song intervention, Phillip’s perfor- the ‘‘good-bye’’ step was eliminated and the caregiver
mance was back at baseline level. By the forth day of left the classroom as he entered (Condition C). This
intervention, Phillip’s performance was above baseline produced an abrupt and sharp increase in the number of
level and by the sixth session, Phillip’s performance steps completed independently. He consistently had
was consistently higher than the baseline level. The three of four steps done independently. After five ses-
trend during the intervention condition indicates sions of stable performance, the intervention was

Baseline Intervention Baseline Intervention


Number of Independent Responses

5
Baseline Intervention Modified Baseline Modified
Number of Independent Responses

Intervention Intervention
5
4

4
3
3
2
2

1
1

0 0
0 2 4 6 8 10 12 14 16 18 20 22 24 26 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32
Sessions Sessions

Fig. 1 Number of independent responses performed by Phillip Fig. 2 Number of independent responses performed by Ben
during the morning greeting routine in baseline and intervention during the morning greeting routine in baseline, intervention,
sessions and modified intervention sessions

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J Autism Dev Disord (2007) 37:1264–1271 1269

withdrawn. An immediate decrease in his independent whether teachers could implement the songs in the
behavior occurred. With the re-introduction of the context of that routine after receiving consultation and
intervention, the data resulted in an abrupt and sharp training from a music therapist; and, finally, whether use
increase in the number of independent steps. Ben of the songs influenced classmates’ greetings to one
completed all four steps independently. This high level target child. As shown, the data support the use of
of performance was stable during the last condition. individualized songs implemented in this manner to
The number of peers who greeted Ben without adult facilitate independent entry into classrooms. As such, it
prompting are shown in Fig. 3. During the initial adds to the literature on how to include young children
baseline condition, no peers greeted Ben during the with autism in inclusive classrooms (Strain et al., 2001).
greeting routine. With the use of the song intervention, In this study, individualized greeting songs matching the
two peers greeted him independently on 9 of 12 days, participants’ personality (based on the music therapist’s
and four, three, and one peer greeted him on the judgments) and the demands of the morning greeting
remaining days. With the modified intervention, two routine were effective in facilitating a smooth transition
peers greeted him on three of five days, but on one day from home to the child care program. These findings
no peers greeted him and on the other day, one peer support the recommendation to use songs to ease
greeted him. The removal of the song in the second transitioning for individuals with autism (Baker, 1992;
baseline resulted in more variable data. Two peers Furman, 2001; Gottschewski, 2001).
greeted him independently on two of five days; on the These effects occurred, with the teacher rather than
second day, three peers greeted him, but on the last the music therapist implementing the songs in the
two days, one peer greeted him. The reintroduction of morning greeting routine. The teachers did not use
the modified intervention resulted in two peers greet- songs for this purpose prior to this study, did not know
ing him on three of four days, with one peer greeting the songs until they were taught by the music thera-
him on the first day of the condition. Thus, initiation of pists, and did not have formal musical training or
the song intervention resulted in an increase in the experience with music therapy interventions. In addi-
number of peers greeting Ben, but withdrawal of the tion, the training time was relatively short. This study
song in the second baseline did not result in data pat- replicates and extends earlier studies showing that
terns similar to the first baseline. Neither the modifi- classroom teachers can embed intervention strategies
cation of the intervention nor the withdrawal of the successfully into ongoing routines, when training and
song intervention returned the peers’ behavior to monitoring were provided (Kemmis & Dunn, 1996;
baseline conditions, with the exception of one day. Venn et al., 1993). However, despite their success,
teachers were challenged with parts of the musical
characteristics of the songs. For example, in both cases
Discussion the teachers did not implement the change in music
indicating the good-bye part of the songs (step four of
This study evaluated the effects of embedding a music the greeting routine). Interestingly, and perhaps coin-
therapy intervention (using original greeting songs) in cidentally, it was exactly this part that distressed both
the morning arrival routine on the independent func- target children. This raises the question if the imple-
tioning of two young boys with autism. It also examined mentation of the change in music signaling the ‘‘good-
bye’’ part would have changed the target children’s
performance during this step. No data are available to
5 Baseline Intervention Modified Baseline Modified
suggest the change in the music would produce positive
Number of Peers Greeting Ben

Intervention Intervention

4 outcomes, but future research should examine this


possibility. Other explanations exist for the children’s
3 difficulty with this step such as the lack of under-
standing of conventional gestures and the fact that it
2
signaled the caregiver leaving. Clearly, high quality
1 staff development activities and ongoing collaborative
consultation seem to be critical components for
0
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 appropriate and successful implementation of teacher-
Sessions mediated interventions using music therapy principles.
Fig. 3 Number of peers greeting Ben during the morning
In this study, maintaining teacher’s comfort level,
greeting routine in baseline, intervention, and modified inter- motivation, and monitoring of the teachers’ use of the
vention sessions procedures were needed.

123
David Aldridge Collected music therapy papers 119
1270 J Autism Dev Disord (2007) 37:1264–1271

The use of the songs also potentially had positive songs for each child; thus, these data do not indicate
effects on peers’ greeting behavior and interaction whether a teacher, without assistance from a music
toward the target children. This was noted informally therapist, could adapt a pre-composed song (referred to
for Phillip and then measured formally for Ben. Peers as the ‘‘Piggybacking’’ technique) and produce similar
volunteered in singing and greeting the target children results. Another limitation concerns the lack of mainte-
during their morning arrival time, or participated by nance and generalization data.
giving their input to the song (e.g., statements about This study suggests future studies should focus on
the weather condition) while engaging in other activi- the effects of songs in other challenging routines for
ties. The song intervention seemed to pique the inter- young children in inclusive classes. Similarly, studies
est of peers and evoke a positive view toward Ben. This focusing on using songs to promote other skills (e.g.,
change seemed to be affected by the intervention alone social and communicative abilities) should be imple-
and was not contingent on Ben’s performance. That is, mented. Finally, systematic studies of the effects of
the greeting song motivated the peers to interact with songs designed for young children with autism should
Ben, but his performance did not change until after the contain measures of the effects on their peers. Do such
peers had regularly greeted him. However, the number songs change the behaviors and attitudes of peers
of peers greeting him did not return to the levels of the toward their classmates who have autism?
initial baseline during the second baseline condition.
The teachers, parents of the target children, and Acknowledgement This study is a part of a series of single case
studies investigating embedded music therapy interventions for
parents of other classmates reported the intervention the inclusion of young children with autism spectrum disorders in
was effective and valuable. The mother of one of a community-based, university-affiliated Family and Child Care
Phillip’s peers said that before the intervention her Program. The authors wish to acknowledge Dr. Ann N. Garfinkle
child was intimidated by Phillip’s inappropriate for her contributions to the study. Gratitude also goes to the
children and families, teachers and colleagues for their partici-
behavior at greeting time. With the implementation of pation, dedication, and collaboration in this study.
the song, this classmate ran to school hoping to arrive
before Phillip so he could participate in Phillip’s
greeting song. Phillip’s mother reported she was very
pleased by the success of the intervention and References
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The Arts in Psychotherapy, Vol. 20, pp. 285-297, 1993 0197-4556193 $6.00 + .OO
Printed in the USA. All rights reserved. Copyright 0 1993 Pergamon Press Ltd.

HOPE, MEANING AND THE CREATIVE ARTS THERAPIES IN THE


TREATMENT OF AIDS

DAVID ALDRIDGE, PhD*

What strikes me is the fact that in our society, definition and thereby elusive to measurement (Feifel,
art has become something which is related only 1990). However, they are amenable to artistic expres-
to objects and not to individuals, or to life. That sion in that they can be written as poetry, acted as
art is something which is specialized or done by drama, moved as dance, drawn, sculpted and painted
experts who are artists. But couldn't everyone's as art, told as stories and played as music.
life become a work of art? Why should the lamp Creative arts therapies (music therapy, art therapy,
or the house be an art object, but not our life? dance therapy, drama therapy and poetry therapy)
Michel Foucault (in Rabinow, 1986, p. 350) have been developed for use in predominantly psy-
chotherapy settings. Some creative arts therapists
The general proposal of this paper is that the cre- have developed the work with the dying in hospice
ative arts therapies have a significant role to play in settings (Dessloch, Maiworm, Florin, & Schulze,
the treatment of AIDS patients. Not only do they offer 1992; Frampton, 1989) and Lee (199 1) has developed
an existential form of therapy that accepts patients as the use of music therapy both with cancer patients in
they are and affords them an opportunity to define the hospice setting and with AIDS patients.
themselves as they wish to be, they are primarily The following sets out some considerations that we
concerned with aesthetic issues of form and existen- may wish to incorporate into our treatment and re-
tial notions of potential rather than concepts of pa- search initiatives. As the treatment of AIDS patients
thology. That the persons are infected with a virus occurs predominantly in a medical setting, it is nec-
recalcitrant to medical initiatives is a given and is essary to present some of the medical understandings
inarguable. What the persons will become and how a of the problem in the first part of this paper. Those
personal future is defined, a future admittedly re- medical understandings, however, are partial. Medi-
stricted and often tragically curtailed, are matters for cine is a restricted set of practices from the repertoire
joint therapeutic endeavor between therapists and pa- of our possible healing strategies. What we also need
tients and are not accessible to a normative medical are understandings gained from existential psychol-
science (Aldridge, 199la). ogy and the creative arts themselves. Such under-
The end stage of our therapeutic endeavor is that standing~will be attempted in the latter part of this
the patients will die. This raises important questions paper.
about the nature and goals of therapy, with important
implications for establishing the criteria for measuring AIDS Definition
or assessing the efficacy of our therapeutic endeavors.
Many of the considerations we need to make, partic- AIDS (Acquired Immunodeficiency Syndrome) is
ularly with the dying, are not amenable to operational clinically complex. The process begins with infection

*David Aldridge is Associate Professor of clinical research methodology in the medical faculty of Universitat Witten Herdecke, Germany,
and European Editor of The Arts in Psychotherapy.
285
David Aldridge Collected music therapy papers 122
286 DAVID ALDRIDGE

through the bloodstream with the Human Immunode- dependent upon the individual. However, the social
ficiency Virus (HIV). Initially there are no obvious and psychological conditions in which the infected
symptoms. However, after about 4 weeks flu-like persons live are also contributing factors to the devel-
symptoms may occur, indicating an immune reaction. opment of AIDS. As we are now becoming increas-
This reaction is the body's normal way of removing ingly aware of the influence of lifestyle upon immune
infections. What then occurs is the most dangerous capabilities (Ader, 1987; Darko, 1986; Solomon,
part of the viral activity that makes HIV so intractable 1987), it is in this arena of contact that we may be best
to treatment. The immune system is in part composed able to offer therapeutic help. An already weakened
of "helper cells." It is these cells that act as a host to system is further weakened by the threat of a lingering
the virus which then changes their structure. Every death, social isolation and condemnation. The contact
time an immune reaction occurs in the body the virus between arts therapists and patient is the opposite to
is replicated. What was formerly "helping" is now that of isolation in that it offers the patient the chance
"infecting. " However, it must be stressed that not all to be a partner in a creative process that is without
HIV-infected patients will undergo this process of se- stigmatization.
roconversion (i.e., changed immune status). There is a considerable bodv of work on the rela-
The stage is set for the development of AIDS, the tionship between life events and psychological disor-
development of which varies from individual to indi- der, which has been extended to working with AIDS
vidual. As the immune system deteriorates there are patients (Atkins & Amenta, 1991; Blaney et al.,
increasing possibilities for opportunistic infections. It 1991; Dew, Ragni, & Nimorwicz, 1991; Ross, 1990).
is often these infections from which the patient even- In a study to determine the extent to which stigmati-
tually dies. As a condition, AIDS was characterized zation influences mental health in 80 homosexual
by the following symptoms: (a) common infections, men, there were significant associations between life
like pneumonia, to which the body has no immunity, events and mental health. Events related to AIDS had
(b) the development of malignancies like rare skin the highest correlations (Ross, 1990). Ross suggested
cancers and (c) neurological disorders sometimes that the impact of life events may be amplified by
leading to dementia. However, a new AIDS definition stigmatization and that degree of life change is asso-
has been proposed by The Centers for Disease Control ciated closely with psychological dysfunction. He
in the United States regardless of symptomatic ex- concluded that life events, which are related to both
pression to include those people who are seropositive stigmatization and related emotional distress, are sig-
for HIV and have a particular white blood cell count nificant predictors of psychological dysfunction.
(CD4 T-lymphocyte) of less than 200Ipl (Editorial, For every patient living with the diagnosis of AIDS
1992; Nelson, 1992). The result of such a decision for or a positive HIV test result this means a turning point
research is that it will be easier to define cases. In in his or her life. It is existential uncertainty and un-
practice such a decision means that the incidence of predictability that lie at the root of post diagnostic
AIDS will rise sharply. Recently new AIDS indica- problems. Although the need for early treatment is
tors of the disease have been recognized as pulmonary evident, this also means a personal exposure to social
tuberculosis, recurrent bacterial pneumonia and inva- scrutiny. AIDS is seen as threatening, as is no other
sive cervical cancer. The inclusion of pulmonary tu- current disease. This is in part exacerbated by infor-
berculosis has "more to do with efforts to control mation campaigns. Once the diagnosis is made, the
tuberculosis among HIV-infected populations than its whole texture of social life and intimate relationships
value as an indicator of severe immunodeficiency" changes radically. Any future perspective on life is
(Editorial, 1992 p. 1200; Nelson, 1992). We see here inhibited by the possibility of repetitive stays in hos-
that even in the apparently simple process of case pital and a deteriorating physical and mental status.
definition, considerations of social control are raised, Physical problems go hand in hand with emotional
echoing the stigmatization of tuberculosis patients in problems, and these occur in a context of personal
the earlier part of this century. relationships. The consideration of physical, emo-
tional and relational problems together is sometimes
Immunity, Life Events and Social Context known as the biopsychosocial model (Engel, 1977;
Sadler & Hulgus, 1990). Using such a model, Wolf et
AIDS is how the immune system reacts between al. (1991) evaluated 29 symptomatic and asymptom-
viral infection and the development of AIDS and is atic HIV-infected homosexual/bisexual men between

David Aldridge Collected music therapy papers 123


CREATIVE ARTS THERAPIES IN TREATMENT OF AIDS 287

18 and 45 years old in the areas of psychiatric1 (Hays, Catania, McCusick, & Coates, 1990), those
psychosocial, neuropsychological, family and irnrnu- men reported high levels of anxiety, depression and
nological functioning. The outcome measures were help-seeking from their social networks. High per-
mood disturbance, psychological distress and white centages of AIDS-diagnosed men sought help from all
blood cell count (CD4). The most significant other sources (peers, professionals, family), whereas non-
family member, as selected by each subject, com- diagnosed men were more likely to seek help from
pleted family measures. The subjects experienced peers. Regardless of the men's HIV status, peers were
psychological distress and neuropsychological prob- perceived to be the most helpful source. Family mem-
lems. Coping was related to enhanced mood as was bers were less likely sought and were perceived as
perceived social support, which was also related to least helpful. However, in other studies, family and
lower psychological distress. Higher levels of neuro- friends appear to play an important, if sometimes am-
psychological functioning (verbal memory, visual biguous, role in caregiving. The psychological burden
memory, motor speed and visual-motor sequencing) of the families and health workers involved in their
were associated with enhanced psychosocial function- treatment of AIDS patients is probably greater than
ing andlor immunological status. The authors con- that of any other medical condition (Maj, 1991).
cluded that it is important then to make longitudinal In a study by Atkins and Amenta (1991), family
studies using a multidimensional approach in which adaptation to AIDS and to other terminal illnesses
HIV-infected persons and their most significant other was compared by measuring the number of stress-
family members are evaluated. ful events experienced by the family after diagnosis
The suicide rate in persons with AIDS is signifi- and role flexibility in response to medical stressors.
cantly higher than in the general population (Cohen, Families of AIDS patients had significantly more
1990; Grant & Hampton Atkinson, 1990). Grant stress, more rules prohibiting emotional expression,
(Grant & Hampton Atkinson, 1990) remarked that lower trust levels and more illness anxiety than other
although some subgroups of HIV-positive individuals families.
(e.g., military samples) may be at heightened risk for In young children with AIDS, with the exception
suicide, systematic studies showing an increased risk of transfusion-infected children, there is necessarily
for suicide are lacking. Schneider considered suicidal the presence of an infected adult, usually the mother.
ideation among relatively asymptomatic HIV-positive The problem in such a situation is not that of a child
gay men as a cognitive coping strategy that may al- with a fatal illness but that of an entire family. In a
leviate emotional distress (Schneider, Taylor, Ham- study of 30 natural caregivers (mostly mothers but
men, Kemeny, & Dudley, 1991). Certainly the pic- also fathers, aunts and grandmothers), most of the
ture is complex. Risk factors for suicide in the general caregivers were economically disadvantaged and
population include hopelessness, impulsivity, sub- needed help in coping with stress and their life situ-
stance abuse disorder, recent illness, recent hospital- ation (Reidy, Taggart, & Asselin, 1991). Their need
ization, depression, living alone and inexpressible to confide in others was frequently not met although
grief. These factors are present in particular AIDS they responded well to medical care, support and
patients who are depressed, lonely and isolated and at advice.
high risk for suicide. Marital break-up or a failing
relationship that eventually ceases is a significant fea- Social and Ethical Aspects
ture leading to such loneliness. As Blaney remarked
(Blaney et al., 1991), the lack of social support is a Few diseases since syphilis in the 19th century and
strong predictor of psychological distress and is im- tuberculosis in the early part of this century have
plicated in the control of chronic disease. Suicidal raised the ethical, scientific and economic questions
behavior may be the end stage of a process of increas- that AIDS has. The moral responsibility of the ther-
ing psychological distress related to both failing apist to offer unconditional care for the patient has
health status, because of increasing symptoms, and been threatened. The scientific principles of placebo
increasing isolation. trials and safe drug testing procedures have been con-
sistently challenged by the community of AIDS ac-
Help-Seeking tivists (Faden & Kass, 1990), and the cost of health
In a longitudinal survey of help-seeking and psy- care provision for European and American health care
chological distress among San Francisco gay men systems is potentially crippling. Furthermore, the dis-

David Aldridge Collected music therapy papers 124


288 DAVID ALDRIDGE

ease has struck our modem society at its most vulner- remain divided and powerless. Furthermore, as a pro-
able point in raising the issue of how we care for the portion of the AIDS-infected population is drug users,
sick, the poor and those we label as deviant (Acker- the very virus is associated with an already socially
man, 1989; Ribble, 1989). Not only are patients in- stigmatized group. As Ribble (1989) pointed out, a
fected with a recalcitrant virus, they are often infected nurse may feel a strong empathy for the sexually-
by our attitudes of intolerance and condemnation infected partner of an intravenous drug user, yet sig-
(Johnston, 1988). nificantly less empathy for the infected drug user.
As some of those persons contracting the AIDS
virus are likely to belong to groups that are socially Maintaining Integrity and Hope
vulnerable-homosexual men and women, the urban
poor of ethnic minorities and drug users-the chal- The immune system is the biochemical part of our
lenge of offering treatment is one that reaches into the identity. It is not only a system of reaction, but also a
ethical resources of our healing communities. It is proactive system. Its actions are projected into the
precisely the source of contracting AIDS that causes future to develop, restore and maintain our physio-
many of the ethical problems. At a time when appar- logical identity based upon the experiences of today
ently choice of sexual orientation was becoming a and yesterday. Immunological reactions are not only
matter of personal preference rather than solely gen- effects caused by aggressive stimuli; they are also
ital dominance, and the tolerance of homosexual and meaningful memories of our physiological makeup.
lesbian activity was increasing, the AIDS virus served The immune system is the major integrative network
once more to condemn groups of people to the state of within our bodies that facilitates our biological adap-
potential deviancy (Faden & Kass, 1990). tation (Wiedermann & Wiedermann, 1988).
Fear of contagion, coupled with prejudices about For the HIV-infected patient the task is one of
lifestyle, are undoubtedly strong factors of influence maintaining an identity, the source of which is par-
in the way that some caregivers treat their patients. A tially and perpetually self-corrupted (in that the DNA
wide range of emotional reactions by the caregiver material of some cells is changed). This itself calls for
may occur from refusal to provide care, resulting in both an acceptance of self and the realization of a
rejection, to a total immersion in the infected person's creative new self. It also calls for a massive new
needs, leading to burnout. Because irrational fears alignment of bodily immune regulation. Positive
and attitudes play an important role in conditioning emotions are known to be beneficial for the immune
these reactions, education alone for the caregivers system. Yet, it is possible to go further and say that
may not be sufficient to change behavior. Counselling the qualitative aspects of life-hope, joy, beauty and
sessions and mutual support groups are often the most unconditional love-are also vital and beneficial in
appropriate contexts where fears and concerns can therapy. This is precisely the ground in which the
receive an individually tailored response, and where creative arts can have their own being. Patients can
formal and informal caregivers can be helped to man- explore and express their being in the world, which
age stress. is creative and not limited by their infection. From
In contrast to other terminal illnesses, patients can such a perspective we might expect that, although
often clearly say where, when and under what cir- physical parameters may fluctuate or deteriorate, life-
cumstances they contracted the disease. It is these quality measures or existential indicators would show
circumstances that form the axis of judgment about improvement.
the illness~eitherinnocently infected victims or ir- A significant existential beneficial factor in en-
responsible deviants. The conditions governing the hancing the quality of life is hope. Hope has been
attribution of the status sick (Parsons, 1951) are that identified as a multifaceted phenomenon that is a
the sick: (a) do not form groups, (b) recover within a valuable human response even in the face of a severe
prescribed time, and (c) are not causally responsible reduction in life expectation. Herth's (1990) study
for their own demise. The last two of these conditions explored the meaning of hope and identified strategies
are violated by patients infected with the HIV virus. that were used to foster hope in a sample of 30 ter-
Furthermore, the AIDS activists who encourage suf- minally-ill adults. Cross-sectional data were collected
ferers to form groups and advocate for changes in on 20 of the subjects and longitudinal data were col-
treatment and support on their own behalf are threat- lected on 10 of the subjects in order to provide a
ening a longstanding social requirement that the sick clearer understanding of the hoping process during the

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CREATIVE ARTS THERAPIES IN TREATMENT OF AIDS

dying trajectory. Hope was defined by Herth as an more the patient is encouraged to creatively form a
"inner power directed toward enrichment of 'be- new identity.
ing'. " With the exception of those diagnosed with Working with a therapist in a creative way to en-
AIDS, overall hope levels among subjects were high hance the quality of living can help patients make
and were found to remain stable over time. Seven sense of dying (Aldridge, 1987b). It is important for
hope-fostering categories (interpersonal connected- the dying, or those with terminal illness, that ap-
ness, attainable aims, spiritual base, personal attri- proaches be used that integrate the physical, psycho-
butes, light-heartedness, uplifting memories and af- logical, social and spiritual dimensions of their being
firmation of worth) and three hope-hindering catego- (Con, 1993; Feifel, 1990; Gary, 1992; Herth, 1990).
ries (abandonment and isolation, uncontrollable pain The intensification of the inner life through artistic
and discomfort, devaluation of personhood) were activity helps provide a refuge from the emptiness of
identified. existence in a threatened future, but also provides a
Hope, like prayer (Saudia, Kinney, Brown, & platform from which the next existential spring can be
Young, 1991), is a coping strategy used by those made. Having AIDS changes the experience of time.
confronted with a chronic illness, which involves an Many of those who have the disease are young. Sud-
expectation that goes beyond visible facts and can be denly they are faced with a provisional and uncertain
seen as a motivating force to achieve inner goals. existence. Without a goal it is difficult to live for the
These goals change. Although a distant future of life future. To do something positive, to create, to play, is
expectancy no longer exists for AIDS patients, life to take life seriously. The creative act is to take the
aims can be redefined and refocused. With the pro- opportunity to live. The creative act gives us the pos-
gression of physical deterioration, the future becomes sibility to realize something of value in the world.
less defined in time but in the meaning attached to Whereas passive appreciation of art and beauty en-
life events in relationship to meaningful others. In hances our aesthetic appreciation, the act of creation
later stages there is a shift toward less concrete offers a way forward into the future. For those who
goals and a refocusing on the self to include the are suffering, the creative act, no matter how small,
inner peace and serenity necessary for dying (Herth, offers the chance to achieve something concretely
1990). Music therapy, for example, with its ability to (Frankl, 1963). By painting, singing, dancing, acting
offer an experience of time that is qualitatively rich or making music together we can bring the emotion of
and not chronologically determined, is a valuable suffering into the world in a concrete form. Suffering
intervention. made external as expression and brought into form by
The arts therapies, with their potential for bringing art gives the individual the chance to grapple with the
form out of chaos, should offer hope in situations of meaning of that suffering and thereby bring about
seeming hopelessness and are, therefore, a means of change. To quote Frankl (1963):
transcendence. This idea of transcendence, the ability
to extend the self beyond the immediate context to
Whenever one is confronted with an inescap-
achieve new perspectives, is seen as important in the
able, unavoidable situation, whenever one has
last phases of life where dying patients are encour-
to face a fate that cannot be changed, such as an
aged to maintain a sense of well-being in the face of
inoperable cancer, just then is one given a last
imminent biological and social loss (see Figure 1).
chance to activate the highest value, to fulfil the
deepest meaning, the meaning of suffering. For
Implications for Treatment what matters above all is the attitude we take
toward suffering, the attitude in which we take
our suffering upon ourselves. (p. 178)
For many AIDS patients, personal relationships
are deteriorating. Either friends die of the same illness
or social pressures urge an increasing isolation. Spon- The meaning of life is discovered in concrete acts
taneous contacts are frowned upon and the intimacy of creation that are aesthetic. What is internal is ex-
of contact is likely to be that of the clinician rather pressed externally as form. By bringing onto paper, or
than the friend. Creative arts therapies can offer an forming as sound, by moving the body in a sequence
opportunity for intimacy within a creative relation- of dance or creating a narrative with dramatic intent,
ship. This is both nonjudgmental and equal. Once the individual takes responsibility for answering the

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DAVID ALDRIDGE

Coping with physical changes Anticipation of pain


Management of pain
Management of the physical consequences of illness (nausea,
incontmence)and change m physical appearance
Management of the physical consequences of treatment

Coping with personal changes Loss of hope, fitness and identity


Anxiety and depression about the future
Loss of role in family and in employment
Frustration and helplessness

Coping with relationship changes Resolution of conflict


Change in parental roles
Anxiety about the future welfare (emotional and financial)
Anticipated hospital contacts and treatment
Anticipated loss of a family member or partner
Planning the future
Social isolation
Changes in family boundary, and of family and marital
emotional distance
Negotiation of dependendindependence
Saying 'good-bye' and talking about dying
Handling the above personal and physical changes within the
context of an intimate relationship
Changes in, and loss of, sexual activity

Coping with spiritual changes Feelings of loss, alienation and abandonment


Understanding suffering
Accepting dependency
Handling anger and frustration
Forgiving others
Discovering peace
Discussing death
Grieving
Planning the funeral
Discovering hope and the value of living

Figure l. Coping requirements and changes associated with terminal illness. It must be emphasized that these changes have ramifications at
differing levels. Personal changes have implications for an intimate relationship within the family and throughout the social environment
(Aldridge, 1987b, p. 214).

questions life asks. These questions of meaning are ligible and hidden (Arnheim, 1992). As Langer
answered in what we do, that is, concrete activities (1953) wrote, "The function of art is to acquaint the
performed for individual destinies. Thus, the creative beholder with something he has not known before"
act retains its individuality and cannot be prescriptive. (p. 22). Each situation is unique and needs a creative
Furthermore, such an act is aesthetic; it brings into response. In this sense, the creative act is one similar
form, making coherent and manifest what is unintel- to play, which lies between the most personal, inti-

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CREATIVE ARTS THERAPIES IN TREATMENT OF AIDS 29 1

mate and subjective sphere and the external world of Research Suggestions
objects (Winnicott, 1951) in that it bridges the inter-
nal world of the individual with the external world of Because of the nature of the disease and its indi-
the therapeutic relationship (Robbins, 1992). vidual progression it will be necessary to formulate
The art form presents the whole intelligible form as research designs that follow individual patients over
an intuitive recognition of inner knowledge projected time (see Figure 3). Such designs are longitudinal.
as outer form-subjective is made objective but in the There have been calls elsewhere for such longitudinal
terms of the subject and thereby unconventional. In designs, combining scientific and artistic intellectual
artistic expression we have the possibility of making rigor, which follow individual patients as they chart
perceptible an inner experience. Music, drama and their course through the depths and shallows of their
visual art are concerned, not with the stimulation of illness (Aldridge, 199la). In any such study it is also
feeling, but the expression of feeling. It may be more necessary to consider a recurring theme heard from
accurate to say here that feelings are not necessarily varying perspectives. This theme concerns the neces-
an emotional state, but more an expression of what sity to include the views of the partners, or immediate
the person knows as inner life (Aldridge, 1989). family, of patients in any long-term therapeutic initi-
Our treatment initiatives should also be made early atives (Wolf et al., 1991).
in the patient's illness, soon after diagnosis, so that a To carry out such long-term research, which fol-
relationship is made with the patient and with the lows the course of an illness, it is necessary to de-
carers (See Figure 2). The therapeutic relationship velop a core team of practitioners and researchers who
offers intimacy at a time when often the individual is will remain with a project for its duration. The estab-
threatened with isolation and rejection. We can help lishment of such a team is dependent upon adequate
our patients discover their own sense of meaning by research funding, sufficient academic support and
their living out their lives in individual creative acts personal supervision for the personnel to sustain in-
within the context of the therapeutic relationship. terest in a field of work notorious for the toll it takes
Robbins (1992) referred to such situations as "cre- on the professionals involved. As research interviews
ative holding environments" (p. 178). What we need and therapeutic practice can be emotionally demand-
are time and the opportunity to maintain long-term ing, it is imperative to implement adequate supervi-
stability in the relationship, although the physical sion, a feature accepted in therapy but often neglected
consequences of the disease continually remind us of in research.
the precariousness of corporeal existence. It is this As the field of practice is changing rapidly, it is
very balance between the temporal aspects of the important to maintain a review of the current litera-
body and the existential act of living in that body that ture. There are a number of databases that provide
is at the crux of the therapeutic act. background information about the field of AIDS re-

start early after diagnosis


consider creative arts therapies as diagnostic tool
develop a stable team, encourage long-term stability
include the caregivers or partner in the therapy plan
establish a support group for the professional caregiving team
promote teamwork and identify common aims
be ready for changes in physical status of the patient
integrate the physical, psychological, social and spiritual
be aware of the existential anxiety of working with AIDS patients; death, contagion,
sexuality and disempowerment

Figure 2. Treatment recommendations.

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DAVID ALDRIDGE

promote prospective longitudinal studies


develop a stable core research team, academic and clinical
establish ethical guidelines for the use of collected information
install procedure for continuing current literature review
gather data from patients and their partnerdfamilies
consider creative arts therapies as diagnostic tool
identify appropriate health measures; life quality scales, hope index, diary recordings
establish art and music archive of patient creations
distinguish parameters for discerning treatment costs
propose specific hypotheses for doctoral studies

Figure 3 . Research recommendations.

search and that will furnish the research team with is endemic to populations and there is no cure for
valuable insights from other practitioners. AIDS, our research endeavors must include some ap-
With neurological problems a feature of HIV in- praisal of life quality (Catalan, 1990). To this end, the
fection, it should be possible to explore the contribu- use of established life-quality scales alongside indi-
tion the arts therapies can make to the detection of vidual assessment protocols will provide therapists
behavioral and functional changes. Creative arts ther- with feedback about the impact of their work on the
apies appear to offer sensitive assessment tools. They everchanging life of the patient.
can be used to assess those areas of functioning, both There are varying life-quality scales in existence
receptive and productive, not covered adequately by that have been tested for reliability and validity
other test instruments (i.e., fine motor behavior, per- (Aaronson, 1989; Bowling, 1991; Clark & Fallow-
severance in context, attention, concentration and in- field, 1986; Gold, 1986; Oleske, Heinze, & Otte,
tentionality). In addition, they provide forms of ther- 1990; Porter, 1986; Spitzer, 1987). The Hospital
apy that may stimulate cognitive activities so that be- Anxiety and Depression scale was developed from
haviors subject to progressive failure are maintained clinical experience as a brief rating instrument to de-
(Aldridge & Aldridge, 1992). tect the extent of mood disorders as distinguished
Buckwalter (Buckwalter, Cusack, Kruckeberg, & from the physical illness of the patient. Zigmond and
Shoemaker, 1991) described the outcomes of a study Snaith (1983) purposefully excluded all items relat-
involving family members of communication- ing to physical disorder, retaining only items relating
impaired long-term care residents in a collaborative to psychic symptoms that are valuable with AIDS
nursingtspeech language pathology intervention de- patients whose physical condition may deteriorate but
signed to increase the residents' communication abil- psychological condition improve. As a scale in daily
ity. Family members provided memorabilia and arti- use, it has proved to be reliable, easily understood by
facts or produced audio or videotapes for use in con- patients and easy to administer and evaluate by clini-
junction with a speech therapy program. Findings cians (Clark & Fallowfield, 1986). Because the Hos-
revealed that, despite a minimal improvement in pital Anxiety and Depression scale is a self-report
speech ability, there was a dramatic increase in family questionnaire, the patient gives an account of his or
members' satisfaction. As peers, partners or family her own perception of life quality. The generally ac-
play an important role in the process of therapy and cepted, but cruder, Karnofsky Performance Scale
are susceptible to considerable distress too, we must (Karnofsky, Abelmann, & Craver, 1948), while
include assessments of their perceptions of therapeu- weighted toward the physical dimensions of life qual-
tic change. ity, is physician rated and considered to be flawed in
Quality of life has become accepted in the assess- that there are discrepancies between what doctors per-
ment of cancer treatment programs. If the HIV virus ceive and what patients perceive.

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CREATIVE ARTS THERAPIES IN TREATMENT OF AIDS 293

It is important to understand when using such symptoms and in the management of those symptoms.
scales that "quality of life" has a multiplicity of The use of subjects making their own assessments of
meanings and, therefore, to some therapists the scales symptomatology offers a nonintrusive means of gath-
may seem naive and limited. Those researchers who ering data. Perhaps as significantly, the diary also
have developed the scales know themselves that such offers the patient a neutral stance whereby the symp-
limitations exist. Rather than develop an unwieldy toms are assessed methodically and in accordance
global package, some researchers have concentrated with a particular framework designed to be ultimately
on specific items gleaned from a factor analysis of beneficial.
many previously posed questions with an eye to de- The use of diaries has several advantages. First,
veloping a refined clinical instrument. there is the opportunity to provide a daily scoring that
In addition to the quality of life, the fostering of eliminates recall error and in general produces con-
hope is seen as a valuable activity in patient care sistent reporting. Second, there is a comprehensive
(Herth, 1990, 1991). Herth's Hope Index is a useful view of the person's health and the relational context
screening tool that assesses hope over time and vali- of that health status vis a vis other family members.
dates nursing diagnoses of hopefulness and hopeless- Third, symptoms are treated as episodes rather than
ness. Hope is a complex concept with many dimen- solely static events. Fourth, diffuse conditions are in-
sions, yet it is possible, using such a scale, to assess cluded that may not be disabling or necessitate inter-
the way in which patients view their future. vention but that contribute to the profile of the pa-
The message from all of this is to select the re- tient's symptomatology. Finally, diaries provide an
quired test from a number of suggestions according to opportunity to see the way in which problems develop
the particular research question being asked that is over time and the way in which treatment initiatives
appropriate to clinical practice. Clinical scales are can influence such developments. When studying
generally designed as a guide for practice and are easy complex chronic problems, the contextual informa-
to administer. Research instruments are often com- tion over time also illustrates how psychological or
prehensive in scope, time-consuming to administer social factors enhance or complicate the clinical pic-
(occasionally requiring training) and evaluate and rich ture. There is no reason why the recorded data should
in material. Using previously validated questionnaires only be concerned with symptomatic change. A jour-
builds bridges between small initiatives and a greater nal could include poems, drawings and descriptions
body of knowledge, helping the researcher to see the of dreams.
value of his or her work. A benefit of using calendar and diary methods is
Although a research approach in itself, the patient also one of the drawbacks. The data are rich and
diary (Murray, 1985) is an important part of an eval- varied but these cause problems for analysis; there can
uative index. The patient diary is rather a catch-all be too much data. Furthermore, patients can become
term in that some researchers will collect daily data sensitized to their own problems and hence concen-
according to specific rating scales as above. These trate more and more on those problems. This is a
could be more appropriately termed calendar meth- confounding factor for single-case research designs in
ods. An extension of daily rating and subjective com- general where the research process itself becomes a
mentary would appropriately be called a diary. The treatment variable. However, for discovering what a
detailed daily recording of patient commentaries in- patient considers to be important about the treatment
volving introspective accounts may be likened to a process, diary methods are very useful. In the case of
journal and is the least formal, in experimental terms, AIDS patients, feedback, throughout a long therapy
of the three approaches mentioned here (Aldridge, process involving various therapeutic initiatives, is a
1991c, 1992). valuable feature.
In diary studies, the principal collector of data is The above measures are concerned with the health
the patient. One of the tasks of research scientists status of the patient from a particular medical orien-
working in the field of clinical practice is to discover tation, albeit broad in its incorporation of psychical,
what happens in the context of the patient's daily life emotional, psychological, relational and social di-
and to make some attempt to discover how his or her mensions. What is clearly missing is the collection of
problem impinges upon his or her daily routine. Sim- material from the creative arts activities.
ilarly, it is important to discover who in the family of A standard method for active music therapy is to
that person is involved at the time of onset of the make an audio or video recording of the therapy ses-

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DAVID ALDRIDGE

sion and then index this recording after the session. outcome measures (e.g., the ability to care for the
Such material is then available for assessment accord- family, number of days lost from work) and the costs
ing to given criteria and for evaluation for validation of health-care utilization. To do this we need to es-
by peers. Similarly, graphic (Niederreiter, 1990; tablish the routine inclusion of cost data in our studies
Oliveri, 1991) and plastic material produced in the and establish clinical outcome criteria that make sense
studio can be saved to show a progression during the for the patients, clinicians and therapists involved and
course of the therapy. This work can also be photo- the policymakers responsible for third-party methods
graphed when each item is completed or at stages of reimbursement (Aldridge, 1990).
during the course of creation. With new advances in McCormick, Inui, Deyo, and Wood (1991) ob-
computer technology, it is possible to develop photo- served that AIDS has become a chronic disease and
graphs as prints and to commit the same images for the demand for long-term care has increased. The
archiving electronically on a compact disc. Such im- authors studied a cohort of hospitalized persons with
ages then can be saved in a database, displayed later AIDS to determine the proportion and characteristics
on a monitor screen and incorporated into research of 120 AIDS patients who could appropriately be
documents. By saving images over time, it is possible cared for in long-term care facilities with skilled nurs-
to gain an overview of recurring elements, variations ing on the medical wards of five Seattle tertiary care
and changes in composition and form. hospitals. The appropriateness for long-term care was
Although it is difficult enough for music therapists determined by the patients' physicians, nurses and
to agree on an established language for research, there social workers according to four admission criteria:
are grounds to believe that active cooperation is pos- (a) impaired activities of daily living, (b) diagnosis of
sible among creative arts therapeutic disciplines (Al- central nervous system illness or poor cognition, (c)
dridge, Brandt, & Wohler, 1990). It is important that living alone and (d) weight loss. One-third of hospi-
a research structure be established so that creative arts talized persons with AIDS were considered appropri-
therapists meet regularly to discuss their work and, in ate for care in long-term settings, accounting for one-
doing so, develop a common language. Our experi- third of the days AIDS patients currently spend in
ence is that changes in form, whether sculpted, hospitals. These patients can be identified early in
painted, drawn or played, occur concurrently. The hospital stays using a simple clinical index based on
task we face is to correlate such changes in the cre- the criteria above.
ative therapies with changes according to other mea- In formulating such a research proposal it is ap-
sures of health outcome. Furthermore, we need to parent that the suggestions are general. We must de-
establish our expectations of patients in their first velop specific research studies, but as yet have limited
therapy sessions. We know little about how adults experience. The research tradition in the creative arts
spontaneously create in various media (i.e., sing, therapies is limited. Music therapy, in particular, has
move, draw or paint) particularly when they are pre- no established research methodology, although there
viously untutored and unpracticed. is a body of research material in the music therapy and
With the extended costs of health care for the medical press (Aldridge, 1993a, 1993b). There are,
AIDS patient playing a significant role in health-care however, research methods and clinical outcome
delivery, when medical insurance support is likely to measures that can be utilized from other spheres of
be exhausted or, for the poor, nonexistent (Faden & practice. A priority must be to get started doing re-
Kass, 1990), the financial burden of health care is search as a series of longitudinal pilot studies.
going to fall onto the shoulders of the wider commu-
nity. Any new initiatives will need to establish the
cost of treatment over time. Although the creative arts Cautions About Practice and Research
therapies are labor intensive and time consuming, the
potential savings in using fewer expensive pharma- The creative arts can be used as adjuvant therapies
ceutical products, lesser long-term use of medical fa- complementary to medical initiatives in palliative
cilities and possibly extended survival rates are valu- care. In modem scientific medicine, people are trans-
able (Krupnick & Pincus, 1992). The estimates of formed into the subjects of research. They are classi-
such costs will depend upon developing methodolo- fied into disease groupings. This subjectification, and
gies that include clinical outcome measures (e.g., the the conditional requirement that they remain passive
above-mentioned quality of life scales), functional to keep the status "sick" not "deviant," is chal-

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CREATIVE ARTS THERAPIES IN TREATMENT OF AIDS 295

lenged by AIDS patients. In contrast, the creative We know too that patients are socially vulnerable
therapies expect patients to be active self-defining and that their caregivers, particularly in the face of
agents. The requirement is that the patients are moral children with AIDS, are disadvantaged. Poverty is a
(i.e., actively partaking and self-defining) when they challenge to us all in that no matter what therapeutic
are sick and suffering, not that they be subjected to skills we bring to bear and no matter how we strive for
our morality and definition (i.e., passive and judged). our own empowerment, we are continually faced with
Foucault challenged us to find a new truth that is the blight of material neglect. How we care for the
creative and performed free from the politics of med- poor, the sick and the dying, no matter how they
ical authority (Rawlinson, 1987). It is this freedom of contracted their disease, is both a matter of our own
truth and practice that we must encourage with our personal responsibility and a collective measure of
AIDS patients. The therapist and the patient can chal- our humanity (Aldridge, 1991b) .
lenge the notions that we must always be able to do
something and that everything humanly significant is
subject to measurement. Conclusion
At the center of the AIDS debate is a massive
existential anxiety that patients and we as therapists The creative arts therapies, with their emphases on
face. This anxiety is based upon the confrontation personal contact and the value of the patient as a
with death, the fear of contagion, the challenge to our creative productive human being, have a significant
sexual orientation, the exercise of power over another role to play in the fostering of hope in the individual.
and the reality of poverty in a material world. Death, Hope involves feelings and thoughts and necessitates
the inevitable end process of living, so often ignored, action (i.e., it is dynamic and susceptible to human
comes into the foreground, and thereby the normal influence). Stimulating the awareness of living in the
expectation of medical endeavor, that the patient will face of dying is a feature of the hospice movement
recover to a state of normative health, is challenged. where being becomes more important than having.
Contagion, the fear of being invaded, is ever present. The opportunity, offered by the creative arts activi-
Despite our knowledge of the transmission of the vi- ties, for the patient to be remade anew in the moment,
rus, our fears of contagion have little to do with such to assert an identity that is aesthetic in the context of
rationality. For example, in talking with general prac- another person, separate yet not abandoned, is an ac-
titioners and oncologists about working with cancer tivity invested with that vital quality of hope and true
patients, the difficulty for the doctors was the fear of to the quotation at the beginning of this paper. For the
"catching cancer," an irrational fear in a purportedly therapist, hope is a replacement for therapeutic nihil-
rational scientific enterprise (Aldridge, 1987a). ism enabling us to offer constructive effort and sound
Sexuality, which we learn to express and which we expectations (Menninger, 1959).
take for granted as part of our identity, is seen as a Any therapeutic tasks must concentrate on the res-
matter of choice and preference not as solely dictated toration of hope, accommodating feelings of loss, iso-
by our genetic makeup. The notion of "sex" makes it lation and abandonment, understanding suffering,
possible to group together in an artificial unity ana- forgiving others, accepting dependency while remain-
tomical elements, biological functions, conducts, sen- ing independent and making sense of dying. Creative
sations and pleasures suitable to the scrutiny of mod- arts therapies can be powerful tools in this process of
em scientific medicine (Dreyfus, 1987). change, which can be accommodated within an over-
Foucault (1988, 1989) described such a tendency, all rubric of quality of life. Although quality of life
to normalize all aspects of human behavior and bring scales exist for the general clinical population of
them under medical control, as bio-power. The effect cancer patients, they fall short of meeting the re-
of this power on the patient is that he or she responds quirements for individual patients. Expectations of
in the same way to every situation as if the possible life quality differ. Furthermore, the elusive life qual-
responses had become reduced to one form. For ities inherent in creative activities-joy, release,
Foucault, the therapeutic act is to bring about a satisfaction, simply being-are not readily suscepti-
change in such structuring, to give the life of the ble to rating scales. We can, however, hear them
patient the stability and the uniqueness of a work of when they are played, see them when they are painted
art, as we read in the introductory quotation to this or danced and feel them when they are expressed
paper. dramaturgically.

David Aldridge Collected music therapy papers 132


296 DAVID ALDRIDGE

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Aldridge, D. (1991a). Aesthetics and the individual in the practice
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lies outside of the clinic. When clinical care is nec- of life events, hardiness and social support. Journal of Psycho-
essary, we are also best guided to attend to ourselves somatic Research, 35(2-3), 297-305.
and colleagues, too, as we accompany our patients on Bowling, A. (1991). Measuring health: A review of the quality of
life assessment scales. Buckingham: Open University Press.
the long journey that awaits us all. Social disruption, Buckwalter, K. C., Cusack, D., Kruckeberg, T., & Shoemaker,
isolation, conflict and neglect are the doors to the A. (1991). Family involvement with communication-impaired
house of despair. Creative &S therapies must respond residents in long-term care settings. Appl. Nurs. Res., 4(2),
to those who enter that house, but at a social level 77-84.
where we must be the architects of change. People Catalan, J. (1990). Psychosocial and neuropsychiatric aspects of
HIV infection: Review of their extent and implications for psy-
will die. It is what we contribute to the quality of their chiatry. Journal of Psychosomatic Research, 22(3), 237-248.
living that is of importance. Clark, A., & Fallowfield, L. (1986). Quality of life measurements
in patients with malignant disease: A review. Journal of the
Royal Society of Medicine, 79, 165-169.
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Complementary Therapies in Medicine (2005) 13, 25-33

4 Functionality or aesthetics?
5 A pilot study of music therapy in the treatment
6 of multiple sclerosis patients夽
7 D. Aldridge a, ∗, W. Schmid b, M. Kaeder c, C. Schmidt a, T. Ostermann d

8
a Chair for Qualitative Research in Medicine, University of Witten Herdecke, Alfred-Herrhausen-Str. 50,
D-58448, Germany
F

10
b Institute for Music Therapy, Faculty of Medicine, University of Witten Herdecke, Germany

11
c Gemeinschaftskrankenhaus, Herdecke, Germany
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12
d Department of Medical Theory and Complementary Medicine, Faculty of Medicine,

13 University of Witten Herdecke, Germany

KEYWORDS Summary
Music therapy; Introduction: Neuro-degenerative diseases are, and will remain, an enormous public
PR

Matched control group; health problem. Interventions that could delay disease onset even modestly will have
Self-acceptance; a major public health impact. The aim of this study is to see which components of
Self-esteem;
the illness are responsive to change when treated with music therapy in contrast to
a group of patients receiving standard medical treatment alone.
Depression;
Material and methods: Twenty multiple sclerosis patients (14 female, 6 male) were
Anxiety;
involved in the study, their ages ranging from 29 to 47 years. Ten participants formed
Functional scores; the therapy group, and 10 the matched control group matched by age, gender and
D

Aesthetic the standard neurological classification scheme Expanded Disability Status Scale
(EDSS). Exclusion criteria were pregnancy and mental disorders requiring medica-
tion. Patients in the therapy group received three blocks of music therapy in single
TE

sessions over the course of the one-year project (8—10 sessions, respectively). Mea-
surements were taken before therapy began (U1), and subsequently every three
months (U2—U4) and within a 6-month follow-up without music therapy (U5) af-
ter the last consultation. Test battery included indicators of clinical depression and
anxiety (Beck Depression Inventory and Hospital Anxiety and Depression Scale), a
EC

self-acceptance scale (SESA) and a life quality assessment (Hamburg Quality of Life
Questionnaire in Multiple Sclerosis). In addition, data were collected on cognitive
(MSFC) and functional (EDSS) parameters.
Results: There was no significant difference between the music-therapy treatment
group and the control group. However, the effect size statistics comparing both
RR

groups show a medium effect size on the scales measuring self-esteem (d, 0.5423),
depression HAD-D (d, 0.63) and anxiety HAD-A (d, 0.63). Significant improvements

夽 This project was supported by Schering gmbH.


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* Corresponding author. Tel.: +49 2302 926 780; fax: +49 2302 926 783.
E-mail address: davida@uni-wh.de (D. Aldridge).

1 0965-2299/$ — see front matter © 2005 Elsevier Ltd. All rights reserved.
2 doi:10.1016/j.ctim.2005.01.004
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David Aldridge Collected music therapy papers 135
2 D. Aldridge et al.

were found for the therapy group over time (U1—U4) in the scale values of self-
esteem, depression and anxiety. In the follow-up, scale values for fatigue, anxiety
and self-esteem worsen within the group treated with music therapy.
Discussion: A therapeutic concept for multiple sclerosis, which includes music therapy,
brings an improvement in mood, fatigue and self-acceptance. When music therapy is
removed, then scale scores worsen and this appears to intimate that msuic therapy
has an influence.
© 2005 Elsevier Ltd. All rights reserved.

14 Introduction sures by which therapeutics are evaluated, and 58

adopt a pragmatic approach to living as well as pos- 59

15 Neuro-degenerative diseases are, and will remain, sible in the context of a chronic condition.10 60

16 an enormous public health problem. Interventions Although complementary and alternative 61

17 that could delay disease onset even modestly will medicine approaches are being asked for by 62

18 have a major public health impact. These diseases patients suffering with multiple sclerosis, only 63

19 are disabling to the sufferers, there is a loss of nor- a limited number of studies have explored arts 64

20 mal motor functioning, a change in mood, and a and music therapy recently. O’Callaghan,11 for 65

21 gradual loss of cognitive abilities1,2 including audi- example, encourages patients to write songs using 66

22 tory problems3 and memory changes,4 and sensory expressive elements related to positive feelings 67
F

23 processing.5 These multifarious problems worsen for other people, memories of relationships and 68

24 during the course and stages of the disease.1 expressions of the adverse experiences resulting 69
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25 Furthermore, the patient does not suffer alone; from living with the illnesses. 70

26 these losses have an impact upon family and social In a controlled pilot study Wiens et al.12 demon- 71

27 life. strated a potential strengthening effect of music 72

28 Multiple sclerosis is the most frequent in- therapy—–with a focus on breathing and speech—– 73

29 flammable disease of the central nervous system on the respiratory musculature of multiple sclerosis 74

among young adults. It is an autoimmune disease patients. Respiratory muscle weakness is character-
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30 75

31 with additional genetic and environmental factors6 istic of individuals with advanced multiple sclerosis 76

32 and considered to be one disease in the general and can result in repeated infections of the lung. 77

33 class of neurodegenerative diseases. Disease pro- Based on experiences with a music-therapy 78

34 gression differs considerably from patient to pa- group of 225 hospital inpatients with multiple scle- 79

35 tient, so that while we may talk about stages of rosis who participated in a 6-week group music- 80

the diseases there is no typical multiple sclerosis therapy program,13 music therapy appeared to of-
D

36 81

37 patient but rather a heterogeneous group of pa- fer psychological support, relieve anxiety and de- 82

38 tients where generalizations do not really apply.7 pression and possibly help with the difficult process 83

As there are no curative therapeutic interventions, of coping with the disease individually.
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39 84

40 we are reliant upon a palliative intervention. Magee,14—17 also makes use of well-known, pre- 85

41 While medical approaches will undoubtedly fo- composed songs and spontaneous improvisation on 86

42 cus on a functional strategy for treatment, we can- instruments and their attitudes change from a “dis- 87

43 not ignore that these diseases have implications abled self-concept” to a more ‘‘able self-concept’’. 88
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44 for the performance and appearance of the person In a further study,18 the authors showed improve- 89

45 in everyday life. Therefore, we need therapeutic ments in mood state following music therapy, al- 90

46 approaches that include aesthetic performance as though depression was not directly affected. 91

47 well as functional performance.8 Studies into factors governing the quality of life 92

48 Multiple sclerosis patients show increasing inter- for multiple sclerosis patients are interesting in this 93
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49 est in complementary and alternative therapies.9 context. They reveal that patients and their physi- 94

50 One reason is their general disappointment with cians have different perspectives. Physicians deter- 95

51 conventional medicine, since causal treatment is mine quality of life mainly with physical and func- 96

52 not possible; another is a wish to play a more ac- tional parameters, while patients themselves see 97

53 tive role in coping with the disease and a demand psychosocial well-being, emotional stability and 98

for a wider range of therapies to meet psychosocial ways to cope with multiple sclerosis-induced stress
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54 99

55 needs as well. Patients say that by using a com- as the most important factors.19 High levels of de- 100

56 plementary medical approach then they take per- pression and anxiety are associated with people 101

57 sonal responsibility for health, reframe the mea- with MS who seek complementary approaches, al- 102
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David Aldridge Collected music therapy papers 136
Functionality or aesthetics? 3

103 though this may be an underlying factor of chronic encounter and experience. Individual themes and 156

104 illness.20 musical developments emerged for each individual 157

105 The aim of this study is to see which components patient; some wanted to sing and dance, others 158

106 of the illness are responsive to change when treated wanted to be sung to, and others wanted to play an 159

107 with music therapy in contrast to a group of patients instrument or brought their own instruments with 160
108
receiving standard medical treatment alone. them. There were no expectations of previous mu- 161

sical education. The patients wanted recordings of 162

their sessions and their individual selections were 163

109 Patients recorded onto compact discs. They played them to 164

their partners or friends or just listened to some 165

110 Twenty multiple sclerosis patients (14 female, 6 pieces and remembered the condition and feelings 166

111 male) were involved in the study, their ages rang- of the situation. 167

112 ing from 29 to 47 years, with episodic, secondary There was a high degree of willingness on the 168

113 chronic and primary chronic progression and an av- part of all patients to take part in the study, so that 169

114 erage disease duration of 11 years. all rounds of interviews were completed, and 85% 170

115 Ten participants formed the therapy group, and of all music-therapy sessions took place. 171

116 10 the control group. The groups were comparable


117 in the standard neurological classification scheme
118 Expanded Disability Status Scale (EDSS).21 The EDSS Methods 172
119 of both groups was 2.6 on average, which means
that the participants were between normal func-
F

120
A matched control trial was implemented using 173
121 tions (score: 0) and disability that precludes full a battery of indices before therapy began (U1), 174
daily activities (score: 5.5).
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122
and subsequently every three months (U2—U4) and 175
123 Exclusion criteria were pregnancy and mental within a 6-month follow-up without music therapy 176
124 disorders requiring medication. (U5) after the last consultation. 177
125 All participants were informed of the content The test battery included the following instru- 178
126 and details of the study and gave their written con- ments. 179
127 sent to publish the material, especially the video
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128 sequences from the music-therapy sessions. The


129 Ethical Committee of University of Witten Herdecke Indicators of clinical depression and anxiety 180

130 examined the protection of data privacy and the (Beck Depression Inventory and Hospital 181

131 ethical aspects. Anxiety and Depression Scale) 182

132 Patients were matched by the researcher ad-


133 ministering the trial for age, gender, stage of dis- The Beck Depression Inventory (BDI) is an estab- 183

ease and the standard neurological classification lished and reliable questionnaire for assessing the
D

134 184

135 scheme EDSS. The basis for the recruitment pop- severity of depression and offers an instrument 185

136 ulation was from patients coming for their regular suitable to compare this study with other clini- 186
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137 check-ups to the general hospital. A patient was cal studies.23 Patients with multiple sclerosis are 187

138 allocated to the treatment group. The next con- considered to be impaired in identifying emotional 188

139 secutive patient, if matching the previous patient, states from prosodic cues,24 so it makes sense to 189

140 would be allocated to the control group. If not, use such an inventory. 190

that patient would be allocated to the treatment The Hospital Anxiety and Depression Scale (HAD)
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141 191

142 group until the treatment group was complete. Sub- is a self-administered, bidimensional instrument 192

143 sequently, 10 matching control patients were allo- developed to screen for clinically significant de- 193

144 cated. pression and anxiety in medical populations (Zig- 194

145 The patients in the therapy group received three mond, 1983, p. 657). Somatic items are excluded 195

blocks of music therapy in single sessions over to avoid the confounding effect of physical illness.
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146 196

147 the course of the project (8—10 sessions, respec- While it is recognised that patients with multi- 197

148 tively). Patients in the matched control group ple sclerosis have a high lifetime risk for major 198

149 were promised music therapy after the waiting depression, less is known about affective insta- 199

150 period. bility and how symptoms like irritability, sadness 200

151 The music-therapy approach used for this study and tearfulness affect a subject’s overall degree of 201
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152 is based on the Nordoff Robbins approach.22 Both psychological distress.25 Clinically significant anx- 202

153 patient and therapist are active. Music-making on iety, either with or without depression, was en- 203

154 instruments, or singing, and the music itself that dorsed by 25% of patients, three times the rate for 204

155 emerges, all are potential possibilities for activity, depression.26


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4 D. Aldridge et al.

205 Scale for self-acceptance (SESA) Results 256

206 The Scale for the Evaluation of Self-Acceptance Fig. 1 shows the development of the outcome- 257

207 (SESA) is a 35-question scale translated from an measures in the course of time with therapy from 258

208 original scale that assesses the acceptance of U1 to U4 and up to U5 in the follow-up. At the start 259

209 self and others.27 Social support, and coping be- of the study (U1) there was no significant differ- 260

210 haviours, are important for persons afflicted with ence between therapy group and control group on 261

211 multiple sclerosis. A healthy conception of oneself the varying scale measures. 262

212 is central to coping effectively with the day-to-day Significant improvements were found within the 263

213 stresses of modern living. The onset of any neuro- therapy group over time (U1—U4) in the scale 264

214 logical disease, with either actual visible deficits or values of SESA (p = 0.012) for depression (BDI, 265

215 potential future disability, threatens the integrity p = 0.036; HADS-D, p = 0.035) and anxiety (HADS-D 266

216 of that concept.28 subscale anxiety, p = 0.13). Significant differences 267

were found for the control group in regard to the 268

subscale anxiety (HADS-A, p = 0.031), while the val-


217 Hamburg Quality of Life Questionnaire in 269

ues for depression and self-acceptance did not show


Multiple Sclerosis
270

any significant differences over time (U1—U4). No


218
271

differences were found for the functional and phys- 272


219 The Hamburg Quality of Life Questionnaire in Multi- iological values (MSFC, EDSS) and quality of life 273
220 ple Sclerosis (HAQUAMS) is a disease-specific qual- (HAQUAMS). The latter is probably because the 274
ity of life instrument for MS. There are 38 items
F

221
HAQUAMs quality of life is mainly assessed from 275
222 about physical, psychological and social functions statements of physical well-being and mobility thus 276
and questions about symptoms, progression of the reflecting scores on the functional scales. How-
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223
277
224 disease and general impairment.29 ever, there was no significant difference in the 278
225 People suffering with multiple sclerosis identify improvement from U1 to U4 between the music- 279
226 depression and social function as important compo- therapy treatment group and the control group (see 280
227 nents of quality of life (Somerset, 2003, p. 608) and Table 1), although effect size statistics comparing 281
228 including preferences for health states and treat- both groups show a medium effect size on the scales 282
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229 ment alternatives in the decision to initiate treat- measuring self-esteem (d, 0.5423), depression HAD- 283
230 ment for individual patients is seen as an important D (d, 0.63) and anxiety HAD-A (d, 0.63). In the 284
231 treatment consideration.30 follow-up, scale values for fatigue, anxiety and self- 285
232 In addition, data were collected on cognitive esteem worsen within the group treated with music 286
233 (MSFC) and functional (EDSS) parameters. The EDSS therapy. 287
234 describes the state of disability of an MS-patient The use of p-values and effect size are used as 288
and ranges from 0 (normal) to 10 (death due to
D

235
guides in this study as to what may be interesting as 289
236 MS). It is a classification scheme that insures all hypotheses for further studies, or if further studies 290
237 participants in clinical trials are in the same class, are warranted. They are intended as exploratory
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291
238 type or phase of MS.21 It is also used by neurolo- statistics rather than confirmatory. This is a pilot 292
239 gists to follow the progression of MS disability and study and there are considerable limitations both 293
240 evaluate treatment results. Because of its strong in terms of the sample size and a bias in terms of 294
241 emphasis on ambulation, the EDSS is insensitive matching in that there was no random allocation to 295
to changes in other neurological functions and to the treatment group.
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242
296
243 cognitive dysfunction in MS. The Multiple Sclerosis Considering the correlations between the scale 297
244 Functional Composite (MSFC) is a multidimensional scores differences between T1 and T4, we found 298
245 instrument to assess disability of MS-patients. It correlations between the HAD depression index and 299
246 has three parts, testing the function of legs and self-acceptance, and depression on the BDI and HAD 300
walking-ability, the functions of arms and hands and anxiety and depression (see Table 2). We could,
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247
301
248 the cognitive functions.31 The IFSS is a scale that therefore, reduce our battery of tests to the Hospi- 302
249 assesses incapacity and fatigue. tal Anxiety and Depression scale in any future trial. 303

250 For an evaluation of the efficiency and sustained


251 success of music therapy, Wilcoxon-test statistics of
252 outcome-measures differences from U1 to U4 be- Discussion 304
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253 tween the groups were applied to show significant


254 differences. Additionally, effect-sizes were calcu- This study tried to identify factors to be influ- 305

255 lated according to Cohen18 and corrected according enced with a music therapeutic approach in treat- 306

to McGaw and Glass19 . ing patients with multiple sclerosis. Music therapy 307
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David Aldridge Collected music therapy papers 138
Functionality or aesthetics? 5

F
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D PR
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Figure 1 Outcome measures over time. U1—U4: treatment phase, U5: follow-up. Dashed line: control-group, full-line:
music-therapy group. BDI: Beck Depression Inventory, HADS-A: Hospital Anxiety and Depression Scale—–anxiety, HADS-
D: Hospital Anxiety and Depression Scale—–depression, SESA: Scale for self-acceptance (SESA), HAQUAMS: Hamburg
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Quality of Life Questionnaire in Multiple Sclerosis, EDSS describes the state of disability, MSFC: Multiple Sclerosis
Functional Composite, IFFS: Incapacity and Fatigue Scale, MSFC: Multiple Sclerosis Functional Composite.
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David Aldridge Collected music therapy papers 139
6 D. Aldridge et al.

Table 1 Wilcoxon signed rank test comparing therapy and matched control group.
Music-therapy group, Control group, median Wilcoxon signed rank test,
median [25%ile, 75%ile] [25%ile, 75%ile] p significance (two-tailed)
EDSS 2.3 [1.4; 3.5] 2.5 [1.5; 3.6] 0.76
MSFC 0.23 [−0.21; 0.47] 0.14 [−0.45; 0.34] 0.61
IFFS 34.0 [24.3; 45.0] 22.5 [12.8; 47.5] 0.22
SESA 115 [79; 125] 110 [99; 128] 0.59
BDI 13.0 [6.5; 19.0] 7.0 [3.0; 20.0] 0.33
HADS-A 9.0 [4.8; 11.8] 8.0 [3.75;13.25] 0.54
HADS-D 5.5 [3.8; 7.0] 6.0 [1.5; 9.5] 0.84
HAQUAMS 2.3 [2.1; 2.5] 2.0 [1.8; 2.4] 0.07

Difference between intake and end of treatment scores


(Wilcoxon signed rank test)
EDSS MSFC IFSS SESA BDI HADS-A HADS-D HAQUAMS
z −.303 −.507 −1.224 −.533 −.972 −.613 −.205 −1.837
Asymptotic significance .762 .612 .221 .594 .331 .540 .837 .066
(two-tailed)
BDI: Beck Depression Inventory, HADS-A: Hospital Anxiety and Depression Scale—–anxiety, HADS-D: Hospital Anxiety and Depression
Scale—–depression, SESA: Scale for self-acceptance (SESA), HAQUAMS: Hamburg Quality of Life Questionnaire in Multiple Sclerosis,
F

EDSS describes the state of disability MSFC: Multiple Sclerosis Functional Composite, IFFS: Incapacity and Fatigue Scale, MSFC:
Multiple Sclerosis Functional Composite.
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308 can be considered as a part of a treatment strat- there is no cure. This frequently life-long process 326

309 egy for two reasons. One, it offers a means to for patients starting when multiple sclerosis is di- 327

310 improve communicative performance.18 Second, it agnosed obviously demands a range of therapeutic 328

311 promotes the presentation of a self that may be possibilities which must also consider and encour- 329
PR

312 considered as handicapped or degenerating but can age a patient’s creative abilities.33 What we need 330

313 be performed as satisfying and whole—–and that is to establish is which of the varying parameters is 331

314 a matter of aesthetics.8,32 We know from the lim- subject to influence by music therapy, which was 332

315 ited, principally anecdotal, music-therapy litera- the aim of this study. 333

316 ture that there are potential benefits from music In this study various outcome-parameters were 334

317 therapy in terms of enhancing mood and improving evaluated for their possible appropriateness for 335
D

318 self-identity. showing effects of music therapy. These were both 336

319 While there are numerous projects aimed at find- functional and affective. We included many param- 337

320 ing medical relief for suffering and the treatment eters because although the clinicians involved knew 338
TE

321 of disease, we are reminded that disease-related that something positive was happening, there was 339

322 problems influence patient’s mental behaviour and no clear indication of what this was and how to mea- 340

323 this has ramifications for relationships. A major sure it. Through this study we now have an idea of 341

324 confrontation for those offering treatment, as it is what changes and from this basis can develop hy- 342

for the patient, is that the problem worsens and potheses for a controlled study.
EC

325 343

Table 2 Correlation of the differences in scales between T1 and T4.


SESA BDI HAD-A HAD-D HAQUAMS
RR

**
SESA −0.37 (0.11) −0.33 (0.15) −0.61 (0.04) 0.03 (0.89)
BDI 0.57** (0.01) 0.49* (0.03) 0.13 (0.59)
HAD-A 0.41 (0.07) 0.12 (0.62)
HAD-D 0.01 (0.96)
Levels of significance are printed in parentheses. BDI: Beck Depression Inventory, HAD-AS: Hospital Anxiety and Depression
CO

Scale—–anxiety, HAD-D: Hospital Anxiety and Depression Scale—–depression, SESA: Scale for self-acceptance (SESA), HAQUAMS:
Hamburg Quality of Life Questionnaire in Multiple Sclerosis.
∗∗ Correlation is significant at the level 0.01 (two-tailed).
∗ Correlation is significant at the level 0.05 (two-tailed).
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YCTIM 751 1—9


David Aldridge Collected music therapy papers 140
Functionality or aesthetics? 7

344 Positive changes are shown in patients’ de- recognition of their abilities rather than patholo- 400

345 pressed mood, which are also reflected in the gies, and a possibility for them to exercise their 401

346 self-acceptance scale. Given that patients with own agency. 402

347 a chronic disease are also stigmatised,34 and


348 this spoiled identity is further exacerbated by
349 the concept of degeneration,35 then any inter- Qualitative considerations 403

350 vention that improves mood and enhances self-


351 acceptance is valuable in mitigating stigma. We In a final interview, 9 out of 10 music-therapy par- 404

352 know from the anecdotal literature that music ther- ticipants in the study described how important it 405

353 apy is important for establishing and recreating self was to become personally active in their treat- 406

354 identity.15,32,36 Perhaps we should not simply con- ment. All 10 participants reported an immediate 407

355 sider these diseases as neurodegenerative but as improvement in their well-being during sessions. In 408

356 dialogue-degenerative diseases, where there is a eight participants, this improved state continued 409

357 breakdown in dialogue between the sufferer and for some time and was confirmed by partners or 410

358 the community. friends. This is also confirmed by improvements in 411

359 There were no recognizable changes in motor the self-acceptance and depression scales but not 412

360 and functional abilities. The form of creative mu- by quality of life scores. Differences over time in 413

361 sic therapy used here is efficacious for promoting the depression scores and self-acceptance scores 414

362 a positive self-identity and relieving the emotional are highly correlated with each other that may re- 415

363 burden on a patient but not for improving functional flect their common conceptual background. Seven 416

abilities. participants described an enhanced perception of


F

364 417

365 Improvements in patients of the therapy group themselves with an increasing self-confidence over 418

with regard to relieving anxiety and depression, and the course of the therapy. They were increasingly
OO

366 419

367 above all with regard to improved self-acceptance, able to let themselves be surprised by the music as 420

368 are a consequence of the qualitative changes it emerged and by their own previously undiscov- 421

369 brought about in music-therapy encounters. The ered musical skills. Music and music therapy are ex- 422

370 change in the subscale anxiety of the HADS-D in perienced by patients as ‘‘something moving’’ that 423

371 both groups may be an indication that regular shifts negative thoughts about the disease into the 424
PR

372 professional patient care helps reduce depression background and offers a means of expression for 425

373 in multiple sclerosis sufferers. Standard therapeu- feelings of security, freedom and pleasure.38 One 426

374 tic practice is that patients only attend for con- participant relates how she met a friend in the Uni- 427

375 tact with a practitioner or treatment when there versity that she had not seen in a long time, af- 428

376 is a flare up in symptoms. Being recruited into ter treatment. They talked for a while and it was 429

377 a trial and being regularly assessed is also per- only on parting that she told her friend that she has 430

haps an important variable for therapeutic con- multiple sclerosis. This was a shift in her percep-
D

378 431

379 tact. tion of herself as first and foremost ‘‘a sick per- 432

380 There is a worsening of the music-therapy group son’’ to a normal person with other priorities in 433
TE

381 scale scores at follow-up when music-therapy treat- life. 434

382 ment is withdrawn, particularly with regard to self- What is evident from this study is that in assess- 435

383 esteem. This may be argued as evidence of the ing music therapy in terms of meeting patients’ 436

384 temporary effect of music therapy or that music needs then we cannot simply take a functional 437

therapy does indeed have an effect and we see approach alone. Multiple sclerosis patients have
EC

385 438

386 how the patient responds when the therapy is with- a variety of needs, some of these are psychoso- 439

387 drawn. cial and some of these are also aesthetic. An aes- 440

388 The importance of therapeutic contact is re- thetic therapy offers the opportunity to experi- 441

389 flected in a qualitative analysis of the data. Two ence the self not as solely degenerative but also 442

hundred and twenty-six music-therapy sessions as creative. This is a major turn around in self-
RR

390 443

391 were documented on video and evaluated with the understanding and is reflected in both self-esteem 444

392 help of episodes and generation of categories.37 and an improvement in mood. We are not denying 445

393 What emerged from the qualitative aspects of that these patients have a degenerative disease, 446

394 the study were parameters concerning contact be- simply that these patients are not themselves de- 447

395 tween therapist and patient, coping with the sit- generate. In the face of pathology, even in sick- 448
CO

396 uation, the sharing of musical roles, and an abil- ness, we have the potential to be active creative 449

397 ity to structure time and the possibility to initi- agents. Music therapy emphases creative dialogue 450

398 ate changes in play. These factors reflect the needs as an remedy in the face of a dialogic degenerative 451

399 of these patients for a deeper personal contact, a disease.35 452


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David Aldridge Collected music therapy papers 141
8 D. Aldridge et al.

453 We have used effect sizes here, although mod- 16. Magee W. ‘‘Singing my life, playing myself’’: music therapy 515

454 est, to provide a platform for other studies that will in the treatment of chronic neurological illness. In: Wigram 516

T, Backer JDe, editors. Clinical applications of music ther-


455 no doubt improve on what we have attempted. This 517

apy in developmental disability, paediatrics and neurology. 518


456 exploratory study has indicated the potential ben- London and Philadelphia: Jessica Kingsley Publishers; 1999. 519
457 efits of music therapy as an aesthetic intervention p. 201—23. 520

458 concerned with the performance of self in everyday 17. Magee W. Identity in clinical music therapy: shifting self- 521

459 life. At some stage we will also need to consider contsructs through the therapeutic process. In: Miell D, 522
460 editor. Musical identities. Oxford: Oxford University Press;
multi centre trials. 523

2002. p. 179—97. 524

18. Magee W, Davidson J. The effect of music therapy on mood 525


states in neurological patients: a pilot study. J Music Ther
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22; lournal of the Royal Society of Medicine Volume 80 April 1987

Clinical assessment of acupuncture in asthma therapy:


discussion paper

D Aldridge P ~ D P C Pietroni FRCGP MRCP Department of General Practice, St Mary's Hospital Medical
School, London

Keywords: acupuncture, asthma, complementary therapy, controlled trials

This paper is concerned with reviewing the use bioelectric mechanism1.It has been pointed out, how-
of acupuncture for the relief of chronic bronchial ever, that these descriptions are made by 'scientific
asthma, for it is our intention to embark upon a con- apologists'1.
trolled clinical trial of acupuncture therapy in the It is more likely that acupuncture represents many
context of general medical practice. A secondary phenomena and that a primary difficulty, as discussed
property of this paper is a discussion of clinical trial later, lies in a treatment modality that is under-
methodology as applied to a complementary therapy. pinned by an Oriental philosophy being subjected
to an explanation by the differing theoretical
Acupuncture understanding of modern Western medicine.
Acupuncture is a therapy which has gained some
recognition both within the realms of popular prac- Asthma
tice and, perhaps more importantly, within the realm Asthma is a condition characterized by symptoms
of medical practice. The practice of acupuncture is a which are present over long periods of a patients' life.
collection of procedures which include the insertion The number of people with asthma in the United
of needles at specific points of the body for both Kingdom is estimated to be about two million - a
the relief of pain and the treatment of disease, with number too great for the hospital services to provide
moxibustion and cupping. continuing care. Although the condition is often mild
Traditional descriptions of acupuncture are con- and readily treated, for those persons with a chronic
cerned with the flow of vital energy, called ch'i, condition the illness is composed of recurrent crises
along fixed paths called meridians. These are linked and debilitation. Gregg4estimates that the incidence
together with each other and the organs of the body. of asthma in the population is increasing, and in a
Flow of energy along these paths has a circadian form that is frequently more severe than in the past.
rhythm, so that at times and season it may vary. The general practitioner is in a position to identify
Energy in this context has a bipolar character; it can the incidence of asthma, to be involved in preventive
be positive called 'yang', and negative called 'yin'. measures and to offer early treatment. Many persons
The energy within the body, ch'i, reflects both the seen in hospital outpatient departments could be
vitality of the universe and society l. managed just as easily in the context of the general
For a body to be healthy in this system of descrip- practitioner clinic5.
tion, the flow of ch'i in the meridians is normal and Asthma is often refractory to pharmacotherapy,
balanced. Essentially the process is one of maintain- the side effects of which can be distressing. A low-risk
ing balance, i.e. becoming healthy or losing health. form of treatment such as acupuncture could consti-
Diagnosis, too, is seen as a process and takes into tute an advancement in the management of asthma6,
account many factors. It includes a patient history of particularly if used in the context of general medical
changes in behaviour, appetite and emotions. The practice which utilizes elements of patient education
state of the skin, eyes, breath and tongue are noted and a self-care perspective.
for colour, consistency and odour. There are also
special techniques for the evaluation of the flow of Clinical controlled trials of asthma
energy in the 12 meridians, electrical measure- A literature search was carried out using the Medline
ments of skin resistance, and the palpation of skin database through St Mary's Hospital Medical School
subcutaneous tissue. library. The criteria for the search were English
Although the mode of action of acupuncture is not language papers on 'asthma therapy' and 'acupunc-
known precisely, there are a number of suggestions ture' published in the past ten years. Eight
which propose that the mechanism is linked with the studies were discovered having a controlled trial
secretion of endorphins2. Yu and Lee3 suggest that methodology which used either a 'placebo' or 'no
acupuncture relieves that part of the bronchocon- treatment' control group3v612.
striction which does not arise from the constriction Although these trials ostensibly used a controlled
of smooth muscle as a result of chemical mediators. trial methodology, there were many inconsistencies.
The effect of acupuncture in asthma is mediated First, most of the trials had few subjects; the largest
through modification of the reflex component of trial had 111subjects but the rest had no more than
0141-0768/87/
04022203,~0200/0
bronchoconstriction. Other writers invoke the prox- 25. Second, there was a large disparity in the age
@ 1987
imity of the central nervous system projections of the ranges; in one trial the ages ranged from 6 to 71 years.
The Royal acupuncture simulation site and the pain path as the Third, the clinical entities were wide-ranging.
Society of rationale for the selection of treatment loci, humoral- The predominant conclusion of the controlled
Medicine biochemcal mechanisms, neuromechanisms, and the trials was that at best acupuncture resulted in only

David Aldridge Collected music therapy papers 144


Journal of the Royal Society of Medicine Volume 80 April 1987 223

modest improvement in the 'objective' assessment of ture' in these trials differed from needling as a
airways impedance. These objective measures were 'placebo' or 'sham' acupuncture. What the trials
mainly concerned with expiratory flow rates, airway failed to do was realize that even though methodology
conductance and thoracic gas volume. A greater can be applied, if it is applied without understanding
perception of symptom relief was made subjectively simply as a formula then no significant findings
by the patients using self-report measures and diary emerge. To do this abdicates both responsibility
techniques, a point that will be discussed further in science and real discovery. Science is not
later in the paper. methodology;methodology serves science.
How can we as scientists say that we have sub-
Clinical evaluations jected a practice to adequate investigation when we
Two t r i a l ~ were
~ ~ , essentially
~ ~ evaluations by remove from the process that which is essential?
clinicians of clinical practice. A range of symptoms When applied rigidly, clinical trials remove the inter-
associated with asthma were covered, the treatment action between the subject and the researcher. It is
approach being varied according to the presenting this very interaction which is at the very heart of
symptoms. The number of treatment sessions was not clinical practice, and which cannot be removed no
standardized but varied according to the symptoms matter how impersonal we may wish to be. The separ-
and symptomatic improvement. ation of the disease from the person loses those very
The criteria for improvement were subjective and qualities which we need to understand. Diseases may
included the assessments of both practitioner and be treated as aggregates and submitted to statistical
patient. Cioppa13 found that 67% of the patients analysis, but it is individual persons in whom those
improved with acupuncture treatment. The conclu- diseases are located and who confront us in our
sions of this research were that acupuncture appears surgeries.
to: (a) relieve muscle spasm; (b) be useful in subacute Another feature of the clinical trial methodology
onditions; (c) be something other than hypnosis; (d) was that asthma was seen as a homogeneous clinical
Kacilitate manipulation; (e) have an immediate effect; entity. There was no consideration that the symp-
(/) give complete remission - not only palliation - in toms were located within persons who perceived
many cases; (g) give a sense of well being; (h) be a their symptoms differentially, or that asthma in a
valuable adjunct to standard practice. Fuller14 also 6-year-old is qualitatively different from that in a
considered acupuncture to be effective in treating 71-year-old.
chronic asthma and recommended its use. Asthma appears to be tractable to acupuncture
The remaining papers were a collection of miscel- when treated by committed clinicians who use tradi-
laneous reports and letters about the clinical appli- tional techniques. The clinical trials have not
cation of acupuncture, the relationship to general investigated acupuncture as a treatment modality,
medical practice, and replies to letters15z1. but 'needling techniques'. The challenge for clini-
Hossrizzdescribed the use of acupuncture massage cians and researchers is to examine rigorously the
for the relief of asthma in children. This entails a practical effects of acupuncture treatment but from a
number of techniques using pressure a t acupuncture perspective which involves the whole person and the
sites, friction and manipulation. Hossri also used totality of the treatment process.
hypnosis in combination with these techniques.
Acupressure, the substitute of digital pressure for
needling at specific sites, has been used in medi- The way forward
cine and dentistry both for the relief of pain and It is our intention to carry out a pilot study of acupuc-
tensionz3- 2 5 . ture treatment and education classes in the manage-
ment of chronic asthma. Our referrals will be taken

R'iscussion
here is a disparity between the claims of acupunc-
turists as to positive clinical benefit, and the findings
from hospital outpatients where the patients will be
assessed by an external researcher, who will also
carry out the post-trial blind assessment. Of 150
of the clinical trials research, which demonstrates patients who will be recruited to the study, 50 will be
little 'objective' change but does emphasize 'subjec- randomly allocated to an acupuncture treatment;
tive' change. Such difficulties bedevil the assessment another 50 oatients will be allocated to education
of alternative or complementary therapies, particu- classes; and the third group of 50 patients will be
larly since there is a confusion between different offered continuing general practitioner contact only.
levels of measurement - i.e. between that which is All groups will be asked to complete a diary for the
measurable in terms of quantity such as gas volume, eight-week treatment period, and a t a later follow-up
and that which cannot be readily subjected to such period.
quantification such as 'feeling better'. The acupuncture treatment method will be deter-
A more serious critique concerns the controlled mined by the acupuncturist. There-willbe no definite
trial methodology itself. The trials studied here failed fixed number of treatment sessions, but it is antici-
to provide a sample size with sufficient power to make pated that the acupuncturist will attempt to keep
any valid conclusions from the statisticsz6.Further- within the eight-week timescale. The acupuncture
more, the trials really did not investigate 'acupunc- sites will not be controlled, and it is expected that the
ture'. The process of standardizing the treatment acupuncturist will use a traditional pulse diagnosis.
approach removed from the practice itself that which The data collected will cover a broad spectrum of
is the essence of the treatment. By restricting need- information concerned both with the symptoms and
ling sites to specific loci, limiting the number of treat- illness behaviour, as follows:
ment sessions and abdicating the use of traditional (1) impact of asthma upon health (using the
diagnostic practices, the trials were really reduced to Nottingham Health P r ~ f i l e ~ and ' * ~ life
~ style data
testing the insertion of needles a t particular points. It (Social Problem Q~estionnaire*~), and locus of
is therefore not surprising that needling as 'acupunc- control30;
David Aldridge Collected music therapy papers 145
224 Journal of the Royal Society of Medicine Volume 80 April 1987

(2) diary recording of events3133,asthma attacks, 10 Tashkin DP, Bresler DE, Kroenig, RJ, Kerschner H,
use of medication/bronchodilator, night-time disturb- Katz RL, Coulson A. Comparison of real and simulated
ance, time off work, crisis consultations, GP home acupuncture and isoprotenerol in metacholine-induced
visits and scores for wheeze, breathlessness, chest asthma. Ann Allergy 1977;39:379-87
11 Tashkin DP, Kroenig RJ, Bresler DE, Simmons M,
tightness and cough;
Coulson AH, Kerschnar H. A control trial of real and
(3) qualitative measures of practitioner, patient and
simulated acupuncture in the management of chronic
family satisfaction; asthma. J Allergy Clin Immunol1985;76:855-64
(4) knowledge and skills of patient about the 12 Takishima T, Mue S, Tamura G, Ishihara T, Watanabe
management of asthma; K. The bronchodilating effect of acupuncture in
(5) peak expiratory flow. patients with acute asthma. Ann Allergy 1982;48:44-9
The education classes will consist of direct teach- 13 Cioppa FJ. Clinical evaluation of acupuncture in 129
ing about allergens and triggers of asthma (physical, patients. Diseases of the Nervous System 1976;37:639-43
psychological and relational); the correct use of 14 Fuller JA. Acupuncture. Med JAust 1974;ii:340-l
medication, where appropriate, and the broncho- 15 Alien M. Activity generated endorphins: a review of
dilator; and what asthma is in terms of airway their role in sports science. Can J Appl Sport Sci
1983;8:115-33
impedance. Building on this basis there will be an
16 Rebuck AS. The outpatient management of asthma.
opportunity for each person to identify through the Ann Allergy 1985;55:507-10
diaries their own particular triggers. 17 Donnelly WJ, Spyykerboer JE, Thong YH. Are patients
A number of complementary strategies will be who use alternative medicine dissatisfied with orthodox
introduced, including dietary understandings, speci- medicine? Med JAust 1985;142:53941
fic breathing technique, the use of relaxation tech- 18 Bodner G, Topilsky M, Greif J.Pneumothorax as a com-
niques and stress management. It is anticipated that plication of acupuncture in the treatment of bronchial
the people involved in this project will be able to asthma. Ann Allergy 1983;51:401-3
personalize these strategies according to their own 19 Hayhoe S. Effects of acupuncture in bronchial asthma
lifestyles and the contexts in which they become J R Soc Med 1982;75:917
20 Marcus P. Effects of acupuncture in bronchial asthma.
(I
symptomatic.
J R Soc Med 1982;75:670
This pilot study will attempt to meet our earlier 21 Rosenthal RR, Wang KP, Norman PS. All that is
criticisms of controlled trials. Acupuncture will not asthma does not wheeze. N Engl J Med 1975;292:372
be restricted solely to needling, and a range of data 22 Hossri CM. The treatment of asthma in children
will be collected which will include the physical, the through acupuncture massage. Journal of the American
psychological, the relational and the familial. Society of Psychosomatic and Dental Medicine 1976;
23:3-16
Acknowledgment: This research is funded by the Wates 23 Weaver T. Acupressure: An overview of theory and
Foundation. application. Nurse Practitioner 1985;10:38-42
24 Kurland D. Treatment of headache pain with auto-
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